Part 18-1. The Digestive System
PART XVIII The Digestive System
Section 1. Clinical Manifestations of Gastrointestinal Disease
CHAPTER 251 Normal Digestive Tract Phenomena
GI Function
; swallowing in fetus at 12 weeks
; nutritive sucking in neonate at about 34 Weeks
; coordinated oral and pharyngeal movements necessary for swallowing solid
- within 1st mo or 2 of life in term infant
; preferences for sweet and salty foods at 1 mo
; *interest
in solids at 4 mo
Normal Anatomic Variations
; short lingula frenulum (tongue tie)
; surface furrowing (geographic of scrotal tongue)
; bifida uvula
Regurgitation
; result of gastroesophageal reflux
; *occurs
in the 1st 12-18mo
; definition
- effortless emesis, dribble out of infant's mouth, forceful, volume 15-30ml
; remain happy after an episode of regurgitation
; ¡ÚComplication
¨ç failure to thrive
¨è pulmonary disease( apnea or aspiration pneumonitis )
¨é esophagitis
¡Ø85 Pathologic Regurgitation?
; CxÀÌ ÀÖ´Â °æ¿ì
Stools
; consistency
1) Meconium - earliest stools after birth, dark, viscous, gumlike material
2) Transition stools after 4-5 days, green brown often containing curds
; *frequency
0-7/day
- breast fed infants
/ frequent, small, loose st early, infrequent, soft after 2-3weeks
; color little significant except
¨ç presence of blood
¨è absence of bilirubin products
; ¡ÚToddler's
Diarrhea
- intermittent loose stools, between 1 and 3 yrs
- drink frequently(esp. juice) and snack throught the day
- typically, during the days and not overnight, often excessive fluid intake
Proturberant Abdomen
; ¿øÀÎ
¨ç weak abdominal musculature
¨è relatively large abdominal organs
¨é lodortic stance
; palpation of abdomen
¨ç *liver
1st yr of life
- common to palpate the liver up to 2cm below the Rt. costal margin
- soft in consistency
- Riedel lobe : thin projection of Rt. lobe
¨è spleen tip soft
¨é vertebral column
¨ê pulsation of aorta
¨ë normal stool LLQ in descendingor sigmoid colon
GI Blood Loss
¨ç swallowed maternal blood
¨è nasal or oropharyngeal bleeding
¨é red dyes in foods or drinks
Jaundice
# Indirect hyperbilirubinemia
; common in breast fed infants
; benign in full terms, golden yellow color
# Direct hyperbilirubinemia
;
*pathologic, more than 15-20% of
total bilirubin
; intra- or extrahepatic, greenish-yellow color
Chapter 252. Major Symptoms and Signs of Digestive Tract Disorders
Table 252-1
Some Nondigestive tract Causes of GI Sxs in children
Disordered Ingestion
Transfer Dysphagia
; ¿øÀÎ
¨ç part of generalized neurologic or muscular problem - Botulism, diphtheria, cerebral palsy
¨èpainful oral lesions - acute viral stomatitis or trauma
¨é nasal air way obstruction
Dysphagia
; primary motility disorder
- rare
; secondary motility disorder
- repair of TEF, collagen vascular disorder
- achalasia : rare in children
- esophageal web, tracheobronchial remnant : in infancy
- esophageal stricture secondary to chronic GER, esophagitis
- Schatzki ring, esophageal foreign body
Regurgitation
; effortless movement of stomach content into esophagus & mouth
; result of gastroesophageal reflux through incompetent or immature LES
Anorexia
; hunger and saiety center - hypothalamus
Vomiting
; center - medullary vomiting center
/ directly by afferent innervation
/ indirectly by CRTZ(chemorecepter trigger zone) & higher CNS center
; obstruction below the second part of duodenum - bile stained vomitus
¡ÚTable
252-2 Differential Diagnosis of Emesis during childhood
Table 252-3
Causes of
Gastrointestinal Obstruction
Diarrhea
; excessive loss of fluid and electrolyte in the stool
; stool output
- amount 5g/kg/day in young infants ( cf. adult 200g/day )
; stool osmolality - greater than 50 mOsm
; small bowel disease
-
*voluminous diarrhea
; large bowel disease
- less voluminous
-
*dysentery
/ frequent, bloody stool with tenesmus, urgency
# Pathophysiology of secretory diarrhea
; secretagogue such as cholera toxin
--> binding to receptor on surf. epithelium
--> stimulating intracellular accumulation of cAMP or cGMP
; intraluminal fatty acids & bile salts
--> same mechanism
; congenital microvillous inclusion disease
¢ÞTable 252-4
Mechanism of diarrhea
Constipation
; hard stool passed with difficulty every 3rd days
; ¡ÚTrue
Constipation In Neonatal Periods
- hirschsprung disease, intestinal pseudoobstruction, hypothyrodism
; defects either in filling or emptying the rectum
- hypothyroidism, opiate use, hirschsprung disease
# ¢¾Diarrhea·Î
¿ÀÀεǴ °æ¿ì
; involuntary encorporesis
; constipationÀÌ ½ÉÇÒ ¶§ Prox, colonÀ¸·Î ºÎÅÍ watery content°¡ hard retained stoolÁÖÀ§·Î ħÅõÇÏ¿© rectumÀ¸·Î pass
¡ÚTable 252-6
Important Causes of
Constipation
Abd. pain
# 2 fibers
; A fiber in skin & muscle - sharp & localized pain
; C fiber from viscera, peritoneum, muscle - poorly localized dull pain
--> cell bodies in dorsal root ganglia
--> cross midline
--> ascend medulla, midbrain, thalamus
--> pain perception in cortex of postcentral gyrus
# visceral pain : dermatome °ü·Ã
; epigastrium : liver, pancreas, bil. tree, stomach, upper GI
; umbilicus : distal small intestine, cecum, append., prox. colon
;
suprapubic : *distal large intestine, urnaty
tract, pelvic organ
# parietal pain
; C fiber of dermatome T6-L1
; more localize & intense
# ¡ÚStimulus
provoking pain
; tension or stretching
; tissue metabolites
¡ÚTable 252-7 Recurrent Abdominal Pain in Children
¡ÚTable 252-8 Distinguishing Features of Acute GI Tract Pain in Children
GI hemorrhage
¡Ø79 site : lower eso., stomach, colon
¡Ø81
DDx
; hematemesis
- esophagus, stomach, duodenum¿¡¼ bleeding origin½Ã vomiting ½Ã blood ÃâÇö
- coffe grounds
; hematochezia
- stool³» red or maroon blood
- distal bleeding site³ª distal ileum»ó¹æÀÇ massive bleeding
; melena
- distal ileum»ó¹æÀÇ mild to mod. bleeding
- duo.»ó¹æÀÇ major bleeding
- blackened stools of tarry consistency
# *½Å»ý¾Æ±â
ÀÌÈÄÀÇ infant, childÀÇ TMC Á÷Àå ÃâÇ÷ : anal fissure
# *Çе¿Àü±â¿¡ 2nd common Á÷Àå ÃâÇ÷ : Juvenile polyp
Table
252-9 Differential Diagnosis of GI
Bleeding in childhood
Abdominal Distention And Abdominal Mass
# Cause Of Abdominal Distention
; diminished tone of the wall musculature
; increased contents (fluid, gas, solid)
# Cause Of Abdominal Mass
; constipation, fecal mass, anomalies, cysts, inflammation, neoplasm, liver cirrhosis
Section 2 Oral cavity
; ¸ðµç child´Â birth½ÃºÎÅÍ, 1¼¼ Àü¿¡´Â oral health counselling ¹Þ¾Æ¾ßÇÔ.
; visual oral inspection by dentist : 18-24 Mo
CHAPTER 253. Development of The Teeth
; 12wk fetal life½Ã epith. band. ( dental lamina )·Î ½ÃÀÛ
; permanent teeth´Â 5th gest. moºÎÅÍ cryptÇü¼º.( central incisors )
; 1st, 2nd, 3rd permanent molar´Â °¢ 4 mo, gestation, 1yr, 4-5yr¿¡ ³ªÅ¸³².
; 2nd bicuspids : 10 Mo
253.1 Anomalies Ass. with Tooth Development
Anodontia
# *total
anodontia : ectodermal dysplasia
# partial anodontia
; dist. of initiation site (palatal cleft)
; genetic failure
-
¡Úalbright osteodystrophy, chondroectodermal dysplasia,
cleidocranial dysostosis, Hallermann-Streiff, oto-palato-digital type I,
william
; ºÎÀ§
- 3rd molar
- maxillary lat. incisor
- mandibular 2nd molar
Supernumerary Teeth
; maxillary central incisor ¸¹´Ù.
; teeth position & eruption ¹æÇØÇϹǷΠÁ¦°Å
Macrodontia, Microdontia
Twinning
: two teeth joined together
Amelogenesis Imperfecta
; faulty production of organic matrix
Dentinogenesis Imperfecta
; poorly calcified dentition
Localized Dist. Of Calcification
; hypocalcification, hypoplasia
Mottled Enamel
;
*fluoride content of drinking
water > 2.0 ppm
-->
*ameloblastic dysfunction
-->
mottled enamel
Mineral Deficiency
; Vit. D def. rickets, Vit D resistant rickets
¡Ø$ Discolored teeth
1) Neonatal hyperbilirubinemia
;
*blue to black of primary teeth
2) Tetracyclines
;
*brownish yellow discoloration,
hypoplasia of enamel
;
*Pregnant women°ú 8¼¼ ÀÌÀü¿¡¼´Â
CIx.
3) *Porphyria
; red brown
Teething
; irritable
¡Ø81,82°´
Delayed Eruption
1. all teeth
; systemic or nutritional disturbance
i) hypopituitarism
ii) hypothyroidism
iii) cleidocranial dysostosis
iv) 21-trisomy
v) Progeria
vi) Albright osteodystrophy
vii) Incontinenta pigmenti
viii) rickets
ix) Multiple syndrome ; Hunter, Dubowitz, Goltz, de Lange, Gardner, Maroteaux-Lamy
2. single or small groups teeth
i) malpositioning of teeth
ii) supernumerary teeth
iii) cysts
iv) retained primary teeth
*advanced dentition ;
hyperthyroidism, precocious puberty
¡ÚNatal Teeth
; eruption at birth
;
*indidence 1/2,000
; ´ë°³ two in mandibular central incisor
; gingival margin¿¡¸¸ attach ( No root or no bony support )
; *prematurely erupted primary teethÀ̹ǷΠX-rayÈ®ÀÎ Àü¿¡´Â supernumerary·Î »ý°¢Çϸé
¾ÈµÊ
; *asso. disease
- cleft palate
- Pierre Robin synd.
- Ellis van Creveld synd.
- Hallermann-Streiff synd.
;
*¿µÇâ
- looseness & movement¿¡ ÀÇÇÑ 2Â÷ÀûÀÎ ÅëÁõÀ̳ª ¼öÀ¯ °ÅºÎ
- nursing½Ã marternal discomfort : nipple biting
- detached½Ã asp. À§Çè
-
tongue : laceration & tip amputation *(Riga-Fedes
ds.)
# Neonatal Teeth
;
*eruption within 1mo
Exfoliative Failure
; permanent teeth eruption ¶§ primary teeth Å»¶ô ¾ÈµÈ °æ¿ì
Chapter 254. Disorder Of Teeth Ass. With Other Conditions
1) Osteogenesis imperfecta
; hereditary opalescent dentin(=dentinogenesis imperfecta)
2)
¡Ø$
Cleidocranial Dysostosis
; delayed teeth eruption
; primary teeth abnormally retained
; permanant teeth unerupted
; common supernumerary teeth (esp. premolar area)
; erupted teeth
- *no hypoplasia but variation in size, shape
3) Ectodermal dysplasia
; teeth & alv. process°¡ totally or partially absent
4) congenital syphilis ; permanent teeth¿¡ ¿µÇâ
i) screw driver-shaped incisors with central notch
ii) Hutchinson's incisor
iii) muberry molar : lobular occlusal surf. & narrow pinched crown
Table 254-1 Dental Problems Associated with Selected Medical Conditions
CHAPTER 255. Malocclusion
#
¡ÚOcclusal deformity
; leading cause of loss of teeth
class I : normal
class II : *retrognathia
- ¡ãcommon
class III : prognathia
Cross Bite
Open & Closed Bite
Dental Crowding
Thumb Sucking
;
*beyond 6 yr --> poor Px
Chapter 256. Cleft lip & Palate
Cleft lip : mesenchymal layerÀÇ hypoplasia·Î medial nasal & maxillary prc.ÀÇ °áÇÕºÎÀü
Cleft palate : palatal shelves°¡ fusionºÎÀü
¡ÚIncidence & Epi.
1. cleft lip /c or /s cleft palate
;
*1/600
;
*male dominant
; possible etiology
- maternal drug exposure
- syndrome-malformation complex
- isolated-unknown
- genetic factor
2. cleft palate alone
;
*1/1000
3. Increased incidence of associated congenital malf. & impairment in development
Clinical Manifestations
; *unilat. (Lt. > Rt.) or bilateral
Treatment
1. *¡ãImmediate Problem : Feeding
; "Plastic obturator"ÀÇ ÀÕÁ¡
¨ç fluid control¿¡ µµ¿ò
¨è reference plan for suctionÁ¦°ø
¨é stability for lat. arch seg. Á¦°ø
2. * Surgical Closure
1) cleft lip
;
*2 mo with satisfactory weight
gain & without any oral, respiratory or systemic infection
; Z-plasty
; revision of initial repair - 4~5yr
; nasal corrective surgery - adolescence
2) cleft palate
; criteria of the timing
a) cleftÀÇ width
b) existing palatal seg.ÀÇ adequacy
c) surrounding areaÀÇ morphology
d) soft P. & pharyngeal wallÀÇ neuromusc. function
; goal
a) cleft seg.ÀÇ union
b) intellignet & pleasant speech
c) nasal regurgitation ¡é
d) growing maxilla ¿¡ injury¹æÁö
;
*prior to 1 yr to enhance normal
speech development
; beyond 3 yr
- contoured speech bulbÀ» »ç¿ëÇØ¾ß ÇÑ´Ù.
Preoperative and Postoperative Management
; feeding *within 6 hr of operation
; fluid or semifluid diet for 3wks
Complication
1. recurrent O.M.
2. hearing loss
3. excessive dental decay
4. displacement of max. arch & malposition of teeth
5. speech defects -- emission of air from nose, hypernasal quality
Palatopharyngeal Incompetence
; inability to form an effective seal between oropharynx and nasopharynx during swallowing or phonation
; abnormalities in structure or pharynx or muscles
Clinical Manifestation
; hypernasal speech ~ p, b, d, t, h, v, f, s
; constricting movement of nares during speech
; inability to whistle, gargle, blow out candle, balloon inflation
; loss of liquid through the nose when drinking with head down
; otitis media
; hearing loss
; Oral inspection
- cleft palate or short palate with large oropharynx
- absent, grossly asymmetric, or minimal muscular activity of the soft palateand pharynx during phonation or gargling
- submucous cleft t
/ suspected by bifid uvula, palpable notching in post. border of hard palate
Diagnosis
; true lat. view
- one film:at rest, another film:phonation 'u' as 'boom'
- normal function / soft palate contacts the post. pharyngeal wall
-
*this patient / absent contacts
Treatment
; pharyngoplasty
Chapter
257. Syndromes with Oral Manifestation
¡Ø$ Pierre Robin Sequence
1. micrognathia
2. glossoptosis ( & pseudomacroglossia )
3. high arched or cleft palate
; normal size tongue, foreshortened floor of the mouth, reduced buccal cavity
--> air passage obstruction on inspiration
; Treatment
- *in a prone or partially prone position
-
*no necessary of temporary
suturing of ventral surface to lower lip
- no necessary of trachostomy
(due to sufficient mandibular growth within a few month)
Mandibulofacial Dysostosis (=Treacher Collins synd.
or Franceschetti synd.)
; facial Characteristics
- downward sloping palpebral fissure toward outer canthi, colobomas of lower eyelids, shunken cheekbone, blind fistula opening between angle of mouth and ears, deformed pinna, atypical hair growth toward cheeks, receding chin, large mouth
; facial clefts, abnormalites of ears, deafness
; hypoplastic mandible
; autosomal dominant
Unilat. Hypoplasia Of Mandible
; partial paralysis of facial n. macrostomia, blind fistula, deformed ear lobes
; severe facial asymmetry, malocclusion
Facial asymmetry
Ankylosis of TM Joint
CHAPTER 258. Dental Caries
Etiology
1. *Streptococcus
Mutans
; enamel surf. cavitates
--> oral bacteria invasion underlying dentin (esp. lactobacilli)
--> mixed bacterial infection
--> destruction of tooth
2. frequency of carbohydrate consumption
; sucrose in chewing gum
Clinical Manifestation
1. pits & fissure on occlusal surf. of molar teeth
2. contact surface between teeth
3. necks of teeth : rare, but ¡è in nursing bottle caries
4. ¢¾BBTD (Baby Bottle Tooth Decay)
(=nursing bottle caries)
; occurs from sleeping with the nursing bottle
;
occurs *before 18 mo
; only severe dental disease common in children less than 3 yr
; develop additional cavities on smooth surfaces of teeth
; Treatment
- breast-feeding or water bottles
Complication
; *pulpitis->
toothache-> dental abscess, periapical abscess-> sepsis, facial
cellulitis
Treatment
; dentoalv. unit¿¡ localize½Ã´Â extraction or pulpectomy,
; *dentoalveolar
unit³Ñ¾î¼¸é antibiotics
1) infection in vital area
;
*submandibular space -> Ludwig
angina
facial triangle -> cavernous sinus thrombosis
periorbital space -> orbital involv.
; parenteral antibiotics
2) Immunocompr. host, impaired wound healing, endocarditis À§Çè½Ã
; parenteral antibiotics (PC or EM, clindamycin, vancomycin)
Prevention
1. fluoridation communal water (*1.00 ppm )À¸·Î À¯Áö
;
*¡ãeffective
Table
258-1 Supplemental Floride Dosage
Schedule
2. oral hygiene : brushing of teeth
3. diet : 1¼¼±îÁö weaning ÇÏ¿© nursing bottel caries¿¹¹æ
4. dental sealants & plastics
5. high risk pt. identification
i) Sjogren synd.
ii) Mikulicz ds.
iii) chr. GVH ds.
iv) XerostomiaÀ¯¹ß drug Àå±â »ç¿ëÀÚ
CHAPTER 259. Periodontal Disease
; gingiva, alv. bone, perodontal lig.
Gingivitis
# cause
; poor oral hygiene, ANLL, DM, neutropenia, thrombocytopenia, scurvy, hormonal change ass. with puberty & preg.
Teething
; from low grade fever to significant discomfort
Eruption gingivitis
Acute necrotizing ulcerative gingivitis (ANUG :
Vincent Infection : Trench Mouth)
Etiology
; ass. with bacterial flora (spirochetes, fusobacterium)
; etiology, not fully understood
; in young adults & adolescent (esp. protein malnutrition)
-> facial structure necrosis (*cancrum oris, noma)
¢¾Clinical Manifestation
1. *necrosis
& ulc. of erythematous gingiva
2. *adherent
grayish pseudomemb. over affected gingiva
3. fetor oris
4. cervical lymphadenopathy
5. malaise
6. fever
Treatment
; two phase
1) acute : 48½Ã°£ À̳» È£Àü
i) antibiotics (PC or EM)
ii) local debridement
iii) oxygenating agents
iv) analgesics
2) 2nd phase : acute phase°¡ irreversible periodontal ds. ¾ß±â½Ã
Herpetic Gingivostomatitis
¡Ø94 $ Phenytoin Induced Gingival
Overgrowth ( PIGO, Dilantin Hyperplasia )
Pathogenesis
1. direct stimulatory action on gingival fibroblasts
2. gingivitis
*Clinical Manifestation
; *10-30% of DPH-treated pt.
1. gross enlargement of gingiva
2. edema & erythema of gingiva
3. secondary inf. abscess formation
4. migration of teeth
5. inhibition of exfoliation of primary teeth & subsequent impaction of permanent teeth
Treatment
prevention, oral hygiene, gingivectomy
Juvenile Periodontitis
; Ư¡ rapid alveolar bone loss
; °ü·Ã flora
i) Capnocytophaga
ii) Actinobacillus
iii) Haemophilus
iv) Bacteroides
; esp. permanent incisor, 6 yr molar
Acute Pericoronitis
; incompletely erupted toothÀÇ crownÀ» partially coverÇÏ´Â gingiva flapÀÇ infla.
CHAPTER 260. Dental Trauma
Dental Injury
; preschool (1-3yr) : fall, child abuse
; school age (7-10yr) : bicycle, play ground
; adolescent (16-18yr) : fight, athletic injury, automobile accident
Injuries To Periodontal Structures
Concussion
Subluxation
Intrusive Luxation
Extrusive Luxation
Evulsion
;
*replanted within 30min after
injury
--> more than 90% success rate
CHAPTER 261. Common Lesions of Oral Soft Tissue
Oropharyngeal Candidiasis (OPC, Thrush, Moniliasis)
; Candida albicans
Clinical Manifestation
; white plaques covering oropharyngeal mucosa
- detach ½Ã inflammation & hemorrhage
Prognosis
; self-limited
Treatment
;
*topical Nystatin (1,000,000u
4x/d)
# Myelosuppressed Pt.
; systemic candidiasisÃÊ·¡ °¡´É
; *Multiagent Regimen For Prophylaxis
1)
debriding all mucous membrane surface with *povidone-iodine
swabstick 4 times a day
2)
swabbing with on large cotton pledget saturated with *500,000u of nystatin 4 times a day
# ¡ÚChronic
OPC
;
*endocrinopathy, specific cndida
immunodeficiency syndrome(ass. with cutaneous & nail involvement), acquired
immunodeficiency, nutrient problem, broad spectrum antibiotics
Aphthous Ulcers (Canker Sores)
; solitary or multiple painful ulceration
; labial, buccal, or lingual mucosa and sublingual, palatal, or gingival mucosa
; minor ulcer ~ *2-10mm in diameter --> heal spontaneously in *7-10days
; major ulcer ~ greater than *10mm in diameter --> *10-30days
; coalesce into plaques --> *7-10days
Etiology
; activation and accumulation of cytotoxic T cells
--> altered local regulation of the cell-mediated immune system
¢¾ Predisposing factors
1. trauma
2. emotional stress
3. low serum iron or ferritin levels
4. vitamin B12 or folate deficiency
5. malabsorbtion in ass. with celiac or crohn disease
6. mensturation
7. food hypersensitivies
8. allergic or toxic drug reactions
* 14ÀÏ
ÀÌ»ó Áö¼Ó½Ã´Â biopsy
Treatment
1. *0.2%
aqueous chlorhexidine gluconate mouthwash
2. topical anesthetics
1) viscous lidocain(Xylocain)
2) oral rinse with a solution of elixir of diphenhydramine, viscous lidocain, 0.5% dyclonine hydrochloride
3. topical corticosteroid in a mucosal adhering agents
; 0.1% triamcinolone in Orabase
4. topical tetracycline mouthwash
5. systemic therapy
1) corticosteroids
2) colchicine
3) dapsone
Table
261-1 Differential Diagnosis of
Oral Ulceration
Bohn Nodules
; small cystic lesions along buccal & lingual aspects of mand. & maxillary ridges of neonate
; mucous gl. remnant¿¡¼ ¹ß»ý
Dental Lamina Cysts
; small cystic lesion located along the crest of mandibular & maxillary ridges of neonate
Mucocele
; raised bluish vesicle
; commonly in lower lip
; caused by traumatic laceration of minor sal. gl. duct
Fordyce Granule
; multiple, yellowish-white granule in clusters or plaque like area on buccal mucosa or lips
Herpes Labialis
Cheilitis
; dryness of lip, scaling & crackling
- characteristic burning sensation
; fever
; sensitivity to contact substances + photosensitivity to sun ray
; Tx - bland ointment application
Black hairy tongue (Lingua nigra)
; elongation of filiform papillae in front of V-line
; *¿øÀÎ
- prolonged antibiotics esp. oral troche
- bismuth medication
Geographic tongue (Migratory glossitis)
; benign, asymptomatic lesion
; one or more smooth, bright-red patch
- yellow, gray, white membranous margen
; some have anemia, DM, Reiter disease, seborrheic dermatitis, pustular psorisis
; spont. regression, recurrence
Fissured Tongue (Scrotal Tongue)
; deep grooves on dorsal tongue
- pebbled or wrinkled appearance
; *ass.
with
-
infection, trauma, malnutrition, *low vitamin A level
; food prticles & debris trapped in fissures
- irritation, inflammation, halitosis
- Tx
/ careful cleansing with mouth rinse & soft-bristled toothbrush
¡Ø82
Etio of macroglosia
¨çhemangioma, cyst, tumor
¨ècretinism
¨éacromegaly
¨êBeckwith syndrome
¨ëgargoyism
¡Ø87
tongue tie OP time : after 8-10 Mo
Chapter 262. Diseases Of Salivary Glands And Jaws
# ¢¾Bilat. Enlargement Of Submaxillary Gland
; cystic fibrosis
; malnutrition
; transiently during acute asthmatic attack
; AIDS
# Enlargement of parotid gland
;
*chrnic vomiting & aspiration
in achalasia or bulimia¿¡ ÀÇÇØ
¹ß»ýÇÒ ¼öµµ
ÀÖ´Ù.
# Benign Salivary Gl. Hypertrophy Ass. With Endocrinopathy
i) thyroid ds.
ii) diabetes
iii) disorder of pituitary-adrenal axis
¡Ø81ÁÖ Increased secretion of saliva
1. reflux to anticipated feeding or pain
2. irritative lesion in mouth
3. in conjunction with nausea
4. administration of *mercurial compound
5. encephalitis, chorea
6. irritation of teething
7. neurologic impairment - drooling
Recurrent Parotitis
; healthy children¿¡¼, ´ë°³ unilat.
; *pain
(-), º½¿¡ È£¹ß, 2-3ÁÖÈÄ spontaneous subside
Suppurative Parotitis
; Staph. aureus, ´ë°³ unilat.
; Sx. : fever, tender painfully swollen gland
Ranula
; sublingual area¿¡ cyst
; large, soft mucous containing swelling
Xerostomia (dry mouth)
¡ÚEtiology
; fever, dehydration, anticholinergic drugchr. GVH ds, Mikulicz ds., Sjogren synd., tumoricidal radiation
Caffey Ds.
Osteomyelitis
NB : Premaxillary suture
CH : mandible
Reticuloendotheliosis ( Histiocysosis X )
Neoplasms
Benign Tumors
; ossifying fibroma : pinless, unilat. soft tissue swelling
Cysts Of Jaw
; with multiple basal cell nevoid synd.
Malignant Tumors
; Burkitt lymphoma, lymphosarcoma, osteogenic sarcoma, rarely fibrosarc.
CHAPTER
263. Diagnostic Roentgenograms in Dental Assessment
1) Panoramic R. : single image of upper & lower jaw Á¦°ø
¨ç include
i) mandible condyle
ii) inf. border of mandible
iii) max. sinuses
¨è indication
; unerupted teeth, cyst of jaw, missing teeth, Fx., supernumery teeth
2) Cephalometric R.
¨ç child's facial growth assess, sequently
¨è relation of uper & lower jaws
relation of jaws to cranial base
aligment of incisor teeth
relation of teeth to supporting bone
-> in planning orthodontic care & orthognathic surgical procedure
3) Intraoral dental R.
.. one section of mouth
Ix. ¨ç dental caries
¨è extent of dental trauma
¨é position of supporting bone relative to teeth
¨ê stage of periodontal ds.
¨ë dental anomaly immediately around teeth
Section 3. The Esophagus
CHAPTER 264. Development & Function of The Esophagus
#
¡Úswollowing ; 20wk of gestation
#
¡Úsucking & swallowing coordination : 33-34 wk of gestation
# 3 types of eso. waves
i) primary
; swallowingÇÏ¿© food¸¦ stomachÀ¸·Î º¸³»´Â synchronizing waves
; propulsive efforts
ii)secondary
; local distentionÀ¸·Î ½ÃÀÛ
; residual foodÀÌ ÀÖ´Â esophagus¸¦ empty½ÃŰ·Á´Â propulsive efforts
iii) tertiary
;
*non propulsive
;
´Ù¼ö°¡ ³ªÅ¸³ª¸é abnormalÀ̸ç, *chest pain¹ß»ý
# Common Sx. of eso. ds.
; cough or choking with swallowing
; regurgitation or vomiting
; dysphagia
; complete inability to swallow
; pain on swallowing(odynophagia)
; hematemesis
# Diagnostic evaluation
; barium swallow roentgenogram
; fluoroscopy
; esophageal manometry
; pH meter : *most sensitive to detect reflux of acid
; radionuclide scan
; esophagoscopy
Chapter 265. Atresia & Tracheoesophageal Fistula
Incidence : 1/3,000 - 4,500 ( 1/3 ÀÌ premature )
¢¾ Type (5)
1. distal TEF with EA (87%)
2. EA without TEF (8%)
3. H-type (4%)
4. Prox. TEF with EA ( <1%)
5. both TEF ( <1%)
¡Ø81,83 Clinical Manifestation
# ¢¾ Suspected Case
1) maternal polyhydramnios
2) catheter cannot be inserted into stomach
3) excessive oral secretions
4) choking, cyanosis, coughing at feeding
; type ¿¡ µû¶ó ´Ù¾çÇÑ Áõ»ó
; H-type
- recurrent aspiration pneumonia
- delayed for days or even months
;
¡Ø81,
83 ass. anomalies - 50%
-
*cardiovascular anomaly : ¡ã
- VATER syndrome
1) vertebrae defect
2) anal atresia or duodenal atresia
3) tracheoesophageal fistula with atresia
4) extremities anomlies : radial upper limb hypoplasia
5) renal defects
Diagnosis
; *pulmonary
aspirationÀÌ ¿¹ÈÄ¿¡
¿µÇâÀ» ¹ÌÄ¡¹Ç·Î delivery room¿¡¼ Áø´ÜµÇ´Â
°ÍÀÌ ÀÌ»óÀûÀÌ´Ù.
; *inability
to pass a catheter into stomach
-
*abruptly stop 10-11cm from upper
gum line
--> X-ray
/ coiled cath. in upper eso. pouch
/ dilated esophagus with air
; esophagogram : water soluble dye *1cc À̳»
; H-type : videoesophagogram, bronchoscopy
Treatment
; surgical emergency
1. prone position
2. constant suction
3. temp. control, resp. function, management of asso. anomalies
4. ¢¾Occasionally Stage Op.
1) 1st step : fistula ligation + insertion of gastrostomy tube
2) 2nd step : anastomosis of two ends of esophagus
--> *anastomosis 8-10ÀÏ ÈÄ oral feeding
--> *10Àϰ esophagographyÇÏ¿© anast. ÀÇ adequacy °áÁ¤
# Structural malformtions of trachea°¡ ÈçÇÏ´Ù.
; tracheomalcia, recurrent aspiration pneumonia, reactive airway disease
# *Fistula
°¡ ¾øÀ¸¸é, normal tracheal developmentÀÌÁö¸¸
´Ù¸¥ Áúȯ
ÈçÇÏ´Ù.
;
*esophageal stenosis, severe GER
# *Sequelae
; failure to thrive, slow feeding, coughing, choking
Chapter 266. Other Disorders Of Esophagus
Laryngotracheoesophageal Cleft
; TEF¿Í
ºñ½ÁÇϳª *aphonia (+)
Dx. : endoscopy
External Compression
1.* TMC
mass : subcarinal enalrged LN
; Tbc, histoplasmosis, other forms of Pul. suppuration, lymphoma
2. vascualr anomaly in the mediastinum
Esophageal Duplication Cysts
; 2/3°¡ Rt.
; epith.Àº any portion of intestine°¡´É
; ulceration¹ß»ýÇϸé esophagus ¿Í communication
- ÁÖ·Î gastic mucosa originÀÏ °æ¿ì
; Dx. - barium esophagogram
; neurenteric cyst : glial element°¡Áø dupl. cyst·Î vertebral anomaly Áõ°¡
Congenital Stenosis & Webs
; solid food÷°¡½Ã dysphagia
¡Ø81,87ÁÖ Dysphagia Due To Neuromuscular Disease
Table 266-1. Neuromuscular Disorders that may cause dysphagia
Cricopharyngeal Dysfunction
;
*spasm of cricopharyngeal m or
achalasia of superior esophageal sphincter
; intermittent dysphagia, increased pressure in the pharynx
--> *post. pharyngeal diverticulum
Dx. : videoesophagogram of manometry
Tx. : myotomy of C.P. muscle
Cricopharyngeal Incoordination Of Infancy
; Ãâ»ýÈÄ suckingÀßÇϳª »ïų ¶§ choke & asp.
; 6 Mo±îÁö careful feeding by spoon or gavage½Ã È£Àü
Bulbar palsy
; supranuclear : jaw jerk Áõ°¡, spastic CP sign
; lower motor neuron : flaccid bulbar P & facial diplegia -> Moebius synd.
Paralysis Of Sup. Laryngeal N.
; Eti. : unusual intrauterine position
; C/M : dysphagia, eso. motiltity °¨¼Ò, head turning a side
; Px : 1³â³» spontaneous recovery
Transient Pharyngeal Musxle Dysfunction
; palatal dysf. µ¿¹Ý
; delayed develop. or C-P½Ã
; ¼öÀÏ-¼öÁÖ Áö¼Ó
Diffuse Esophaeal Spasm
; cause of chest pain & dysphagia in adolescents
Chapter 267. Achalasia (Megaesophagus)
; primarily *adolescents
and adult
; fewer than *5%
under 4yr
# Pathogenesis
;
*decreased ganglion cell
surrounded by infl. cell
--> heightened response to methacholine
--> degeneration hypersensitivity
¡Ø95$
Fig.267-1
Clinical Manifestation
; swallowing diff.
; regurgitation
; cough
; poor Wt. gain
; reported in sibilings
; *asso. with adrenal insufficiency, alacrima
Diagnosis
;
*esophageal manometry - confirm
-->
*incomplete or absent relaxtion of
the LES with swallowing
--> lack of primary or secondary propulsive peristaltic waves
--> increased LES pressure
Treatment
1. nifedipine ; indicated when brief delay in definite therapy
2. intrasphincter injection of botulism toxin ; as long as 6mo
3. simple bougienage ; temporary
4. *surgical division of muscle fibers (Heller myotomy) ; permanant
Chapter 268. Hiatal Hernia (Partial Thoracic Stmach)
2 Types
1. Sliding hernia
;
*¡ãcommon
; GE junction slides into the thorax
; congenital
; ¡Ú Tx - not hernia but GER
2. Paraesophageal hernia
; stomach insinuated bedside GE junction
; following fundoplication for GER
; fullness after eating & upper abd. pain
; ¡Úinfarction of the herniated stomach - rare
¢ÞChapter 269.
Gastroesophageal
Reflux (Chalasia)
Etiology
1. Contributing factor to competency of LES
1) abd. position of the sphincter
2) angle of insertion of esophgus
3) *sphincter pressure ; major mechanism of reflux
2. Norml person
; reflux°¡ ÀÖÁö¸¸, swallowing of saliva·Î protect
3. decresed gastric emptying and reduced acid clearance
Clinical Manifestation
1. excessive vomiting
; 85% during 1st wk of life
; 10% by 6wk
-->
¡Ø87 by
2yr as upright posture
;
60% Sx disappear
; remainder until 4yr
2. ¢¾ Increased Incidence
; *cerebral palsy, down synd., developmental delay
3. delayed gastric emptying & vomiting
4. aspiration pn. (1/3)
5. chronic cough, wheezing, recurrent pn.
; Sx persist until later childhood
6. rumination
7. growth & wt. gain Àå¾Ö (2/3)
8. Esophagitis
; hemorrhage
--> hematemesis but melena rare
; iron deficiency anemia
; substernal pain rare but dysphagia
--> irritability, anorexia
; stricture formation (5%)
; death due to inanition and pn. (5%)
# ¢¾Sandifer Syndrome
- opisthotonus, abnormal head posturing ass. with reflux
- GER ass. with severe esophagitis, IDA, vomiting, head tilt trait
9. laryngospasm, apnea, bradycardia ; rare
Diagnosis
1. Clinical Assessment With Response To Therapy : Mild
2.
¡Ø89
barium esophagography under fluoroscopy ; severe or complex cases
1) hiatal hernia ; gastric fold above diaphragm
2) GER ; no demenstrated
--> enough barium, special maneuver
3) severe esophagitis ; ragged mucosal outline
3. *Esophagoscopy With Biopsy ; ¡ãspecific
; early changes
- increased thickness of the germinative layer
- increased length of dermal papillae
; severe changes
- intraepithelia neutrophils, eosinophils
- ulcer formation
- presence of columnar epithelium (Barrett esophagitis)
4. gstric scintiscans
5. continuous monitoring of distal esophageal pH
; not needed for routine diagnosis
; atypical symptoms or unusual events°¡ ÀÖ´Â °æ¿ì
¡Ø87ÁÖ
Treatment
1. *prone
position(young infant) & raising head of the bed and keeping the child(older
infant)
2. thickening the feeding with cereals
3. Drug therapy
1) Metoclopramide ; 0.15mg/kg/dose qid (S.E. - drowsiness, restlessness, EPS)
2) Domperidone ; acts only peripherally
3) Cisapride ; 0.2 mg/kg/dose qid
¡Ø96 if esophagitis
1) antacid
2) H2 receptor blocker or omeprazol ¸¦ Ãß°¡
; omeprazol - most effective depression of acid secretion
4. Operation
1) ¢¾Indication
; prolongd trial of intensive medical Tx.¿¡ no response
; recurrent aspiration, apnea°¡ no response
; stricture formation due to reflux esophagitis
2)
*Nissen fundoplication or
variation
5. Percutaneous gastrojejunostomy
Prognosis
; 90% no reflux
¡Ø88 Rumination
; repetitive gagging, regurgitation, mouthing, reswallowing of materal
; uncommon but serious form of chr. regurgitation
; 6-12 Mo¿¡ common, growth failureµ¿¹Ý °¡´É
Etiology
; unknown
; altered interaction with the environment
- prolonged lack of stimulation
- altered relationships with caregivers
¡Ø89 Treatment
1. behavioral therapy ; regular eye contact - mother¿Í intensive relationshipÁß¿ä
2. medical treatment of reflux
3. antireflux surgical procedure
Chapter 270. Esophagitis
Peptic Esophagitis
; *¡ãcommon form of esophagitis
; pain, blood loss, stricture
Retroesophageal Abscess
; Etiology
- extension of retropharyngeal abscess, eso. perforation, spinal O.M., pleuritis, pericarditis, diphtheria of pharynx, suppuration of mediastinal LN
; Clinical Manifestation
- dyspnea, brazzy cough, dysphagia, swelling of neck
; Diagnosis
- increased retrotracheal space by lat. neck X-ray
; Treatment
- prompt surgical drainage
Esohphageal candidiasis (moniliasis)
;
*¡ãcommon esophgeal infection
; not limited to immunocompromised patients
; Torulopsis glabrata
; frequently no oral candidiasis
; Diagnosis
- barium esophagography
/ mucosal irregularities
- esophagoscopy and biopsy
/ most sensitive and accurate diagnostic studies
; Treatment
- ketoconazole
/ 3-6 mg/kg/24hr as a single daily oral dose
- amphotericin and/or flucytosne
/ immunocompromised and systemic infection
Corrosive esophgitis
1. Agents
;
*ingestion of household cleaning
products - ¡ãcommon
; alkalis(70%), acids(20%), bleaches, detergents, microwave overheated baby bottles, button mercuric oxide batteries
1) Alkalis
; severe, deep, liquefaction necrosis on all layers of esophagus
; severe gastritis
; household liquid alkali agents - 8-10% base
; industrial strength alkali agents - 80% base
; no taste --> significant amount ingestion
2) Acids
; toilet bowl cleaners, drain decloggers, rust & stain removers
; coagulative necrosis and thick eschar --> injury on mucosa, superficial muscularis layers of esophagus
; severe gastrits
; bitter --> limiting ingestion
2. Peak age ; less than 5yr
3. Tissue injury sequence
; early saponification, necrosis, thrombosis ( days 1-5 )
; further necrosis ( days 4-7 )
; collagen formation ( days 8-12 )
; healing or stricture formation ( days 8-42 )
#
*esoph. perforation½Ã±â : 7-26ÀÏ
Clinical manifestations
; salivation, refusal to drink, nausea, vomiting, epigastric pain, oral burns or ulcerations, fever, leukocytosis
¢¾Treatment
1. Emergency Management
;
*oral adm. of large quantities of
fluid (water or milk)
-
*neutralization, induced emesis,
gastric lavage - contraindication
; endotracheal intubation or tracheostomy ; edema of pharynx, larynx, airway
2. hospitaliztion
3. NPO
4. ¡Ø96 esophagogastroscopy with flexible fibroptic endoscope
; all patients *within 48hr
--> indentify those /s burns who not need F/U
--> determine the severity of esoph. burn & gastric antral ulceration
5. drug therapy
; ampicillin - suspected infection
cf) perforation with mediastinitis ; broad spectrum antibiotics and mediastinal drains
;
*prednisolone - at now, no
indication
6. intraluminal stents
; risk of stricture
1) circumferential ulcerations
2) white plaque
3) sloughing of the mucosa
; prevention is more important - early detection
7. colonic interposition
Chapter 271. Esophageal Perforation
Etiology
- ´ë°³ instrumentation ½Ã
- eso. pr. ¡è½Ã : violent retching, automobile accidents, compression in birth canal
; Site
-
children : *Lt. of distal eso. (95%)
- neonate : Rt.
Clinical Manifestation
- vomitingÈÄ severe substernal pain, cyanosis attack
# Mallory-Weiss synd.
- violent retching½Ã eso. mucosa & submucosatearing hematemesis
CHAPTER 272. Esophageal varices
; portal hypertensionÀÇ Cx.
¡Ø$ Chapter 273.
Foreign Body In Esohagus
Coins ; *¡ãcommon in esp. less than 5yr
¡Ø81 Physiologic narrowing
i) below cricopharyngeal m.
ii) at the level of aortic arch
iii) just above diaphragm
Clinical Manifestation
1. provoke coughing, drooling, choking
2. pain, dyspnea, dysphagia
Diagnosis
1. radiopaque foreign body ; coin &
flat object on *edge in lat. film
2. symptomatic foreign body ; endoscopy
3. radiolucent foreign body ; barium swallow esophagography
Treatment
1. removal of object under direct vision with esophagoscopy
; ¡ÚEmergency - open safety pins, disc batteries(corrosive injury within 4hr)
2. removal by Foley catheter
3. asymptomatic coin ; observation during 24hr
Section 4. Stomach and Intestines
CHAPTER 274. Normal Development, Structure, Function
Development
8 wk ; peristalsis
10wk ; re-enters of bowel to abdomen
12-13wk ; full development of blood vessels & nerve supply to gut
# acid secretion
; low in the first 5hr
; increase by 24hr
; pepsin secretion peak during the first 10day
; decrease from 10-30days
# disaccharide activity
; 12 wks (+)
; sucrose 24wk
; maltose 32wk
; lactose 36wk
-> decline after the first few years of life
# fat absorption
; term ½Ã less efficient than infant & child
¡ñ lower bile salt synthesis & transport rate
Normal structure
; submucosa : matrix for lymphoid & vascular plexus in duodenum ,Brunner gl. Æ÷ÇÔ.
¡Ø87 4 Types Of Epith. Cells In Small Intestine
1. columnar absorptive cells ; dominate
2. goblet cells ; secrete mucus
3. endocrine cells ; secrete intestinal H.
4. paneth cells : unknown
5. ¡®m¡¯ cells
; over areas of lymphod aggregation
; absorb intact, potentially antigenic proteins
; jejunal epith. ÀÇ complete renewal time : *5-6 ÀÏ
Normal function
; intraluminal digestion
- ÁÖ·Î exocrine pancreas ¿¡ ÀÇÇØ
-
*secretin, cholecystokinin
/
*synth. & secretion of HCO3-
& digestive enzyme
; CHO, protein, fat : ÁÖ·Î SIÀÇ upper portion¿¡¼ Èí¼ö
; Na, K, Cl, water : ´ëºÎºÐ SI¿¡¼
; bile salt, Vit B12 : terminal ileum
; iron : *duodenum,
prox. jejunum
CHAPTER 275. Pyloric Stenosis and Other Congenital Anomalies of The Stomach
# hallmarker of gastric obstruction
: nonbilious vomiting, other Sx. abdominal pain, nausea
# sign of gastric outlet obstruction : abdominal distention and bleeding
# *¡ãcommon cause of nonbilious vomiting : infantile hypertrophic pyloric stenosis
# DDx of CHPS
; pyloric atresia, antral webs, gastric duplication, gastric volvulus
; GER, peptic ulcer disease, salt-wasting adrenogenital syndrome, bezoars, metabolic & motility abnormalities
¡Ø91~96 275.1 Hypertrophic Pyloric Stenosis
; incidence : 3/1,000 in US
; more common in *whites, less common in blacks, rare in Asian
; *M :
F=4 : 1 (esp. 1st born )
# mother ; CHPS
--> 20% of male, 10%of female CHPS incidence
; increased incidence of type B or O blood group
; asso. with congenital defects : TEF
Etiology
Unknown
; abnormal muscle innervation
;
*breast feeding
; maternal stress in third trimester
;
*elevated PG
; reduced level of pyloric nitric oxide synthetase
;
*infant hypergastrinemia
;
*asso. with eosinophilic
gastroenteritis, trisomy 18, Turner syndrome, Smith-Lemli-Opitz syndrome,
Cornelia de Lange syndrome
Clinical Manifestation
1. vomiting
; initial Sx.
;
*nonbilious
;
may or may not projectile initially --> progressive immediately after a
feeding
;
*usually starts 3 wk (1st wk ~ 5th
mo)
2. hunger and wants to feed again after
vomiting
3. *hypochloremic
metabolic alkalosis
4. *maintained
serum K+ but total body K+ deficit
5.
¢ÀJaundice ; 5%
;
decreased level of glucuronyl transterase
;
increased enterohepatic circulation of bilirubin
;
*¼ö¼úÈÄ 72½Ã°£³» ¼Ò½Ç
3. dehydration, lethargy, weight loss, oldman
app.
4. hypochromic alkalosis : °¨¼Ò (s-Na, K, Cl)Áõ°¡ (pH, CO2)
Diagnosis
1. *palpation
of mass(60-80%) : confirm Dx.
;
firm, movable, nontender, 2cm in lenth, olive shapped
; site
-
from left side, above and to the right of umbilicus in midepigastrium beneth
liver edge
;
easier to palpate after vomiting
2. visible peristalsis after feeding, just
before vomiting
3.
¢ÀAbdominal ultra
; *pyloric muscles thickening > 4mm
; *pyloric length > 14mm
;
90%
4. Barium studies
;
'string sign' fine elongated pyloric channel
;
'shoulder sign' bulge of the pyloric muscle into the antrum
;
'double track sign' parallel streak of barium in narrow channel
¡Ø82 Differential Diagnosis
; fed by inexperienced or anxious caretakers
; inadequate maternal-infant bonding
relationship
; emaciated infant ½Ã visible peristalsis
; chalasia, hiatal hernia
; adrenal insufficiency
-
metabolic acidosis, elevated serum potassium, urinary sodium concentration
; inborn error of metabolism
-
*emsis with alkalosis (urea cycle)
- acidosis(organic acidemia), lethergy, coma, seizure
; gastroenteritis
; pyloric memb. or pyloric dupulication
; Duod. stenosis
; achalasia
Treatment
1. Correcting the fluid, acid-base, and
electrolyte losses
;
0.45%-0.9% saline
;
5-10% dextrose with KCl 30-50mEq
-->
¡Útill 1) rehydrated
2)
*serum bicarbonate < 30 mEq
3)
alkalosis corrected
2. Surgical procedure
;
*Ramstedt pyloromyotomy
3. Postop. Care
;
feeding *within 12-24hr and advanced to maintenance oral feedings within 36-48hr
;
¢¾if persistent vomiting(after postoperation)
¨ç incomplete pyloromyotomy
¨è gastritis
¨é hiatal hernia
¨ê chalasia
¨ë other cause of the obstruction
4. Conservative medical Tx
;
*slow improvement, higher
mortality
¨ç *small frequent feeding
thickened with cereal
¨è semiupright position for 1hr or
after feeding
¨é sedation
¨ê adm. of cholinergic blocking
agents
¨ë parenteral
adm. of fluids
5. Endoscopic balloon dilation : trial
Prognosis
; op. mortality 0-0.5%
; medical Tx. ; higher mortality
275.2 Congenital Gastric Outlet Obstruction
; resulting from pyloric atresia and antral web
; uncommon
; 1% of all atresia and diaphragms ass.
with epidermolysis bullosa
; M=F
Clinical Manifestation
; nonbilious vomiting, feeding difficulties
; abdominal distention of 1st day of life
; polyhydramnios, LBW
; rupture of stomach (12½Ã°£ À̳» ÀϾ ¼ö ÀÖ´Ù.)
; antral web : less dramatic
Diagnosis
; plain abdomen : large dilated stomach
; UGI : diagnostic 'pyloric dimple'
; endoscopy
Treatment
; correction of dehydration and
hypochloremic alkalosis
; nasogastric decompression
; OP repair
275.3 Gastric Duplication
; uncommon *cystic
or tubular structures within wall of the stomach
; smaller than 12cm
; not communicated with stomach lumen
; along with lesser curve of stomach
Clinical Manifestation
; gastric outlet obstruction°ú ¿¬°ü
; 33%¿¡¼ palpable
; Tx
-
Op repair
275.4 Gastric volvulus
# Triad
¨ç sudden of
severe epigastric pain
¨è intractable
retching with emesis
¨éinability to
pass a tube into stomach
# Normal stomach
;
tethered longitudinally by the gastrohepatic, gastrosplenic, gastrocolic lig,
gastrophrenic lig. and retroperitoneal attachment of duo.
-->
volvulus ; À§ÀÇ attachmentÁß Çϳª°¡ ¾ø°Å³ª stretch µÇ¾î rotateµÇ¾î ¹ß»ý
# *Asso.
defects
;
*intestinal malrotation,
diaphragmatic defects, asplenia
# Clinical Manifestation
; infancy
- nonbilious vomiting
- rapidly strangulation & perforation
; older children
-
Hx of emesis, abdominal pain, early stiety
# Diagnosis
; plain abdomen
-
dilated stomch
- mesenteroaxial volvulus
/ double fluid level
/ `beak' near the lower esophageal junction
- organoaxial volvulus
/ single air fluid level
/
no ¡®beak¡¯
# Treatment
;
emergency op.
;
*chronic volvulus : endoscopic
correction
CHAPTER 276. Intestinal Atresia, Stenosis, and
Malrotation
General Consideration
1. Incidence of intestinal obstruction :
1/1,500 live birth
2. Classification
1)
partial or incomplete : stenosis,
constricting bands, duplication, incomplete volvulus
complete
: atresia
2) intrinsic : atresia,
stenosis, meconium ileus, aganglionic megacolon
extrinsic : malrotation, constricting bands, intraabd. hernia,
duplication
3) simple
: failure of progression of aboral flow of luminal contents
strangulation : ass.
with impaired blood flow --> bowel infarction and perforation
3. Pathology of intestinal obstruction
;
accumulation of ingested food, gas, secretion prox. to obstruction
-
distension of bowel
-
decreased intestinal absorption & increased secretion of fluid and electrolytes
- isotonic intravascular depletion
-
hypokalemia
-
increase in contractile activity proximal to obstruction
-
marked decrease with hypoactive bowel sound
-
nausea and vomiting due to fluid accumulation & hypomotility
-
decreased blood flow
-
loss of mucosal integrity, bacterial proliferation
-
endotoxemia, bacteremia, sepsis
4. ¡Ø81,82 Polyhydramnios ÀÖÀ»½Ã
;
high intestinal obstruction (esp. esophageal atresia)
-->
gastric aspiration immediately after birth
-->
15-20ml or more gastric fluid or bile stained
-->
suggestive of a high intestinal obstruction
5. Atresia
;
*common ileum(50%), duodenum(25%),
jejunum
;
rare in colon, stomach
;
33% of neonatal intestinal obstruction
;
M=F
Clinical Manifestation
; cause, level of obstruction, time between obstruction and evaluation¿¡ µû¶ó ´Ù¾çÇÏ°Ô ³ªÅ¸³´Ù.
; classic Sx
- nausea and vomiting, abdominal distension, obstipation
; Sx. onset
- Duodenal obstruction : ¼ö½Ã°£³»,
- lower intestine : 24½Ã°£ ÀÌÈÄ
; high intestinal obstruction
- large volume frequent, bilious emesis
- intermittent pain relieved by vomiting
- localized in epigastrium and periumbilical area
- little abdominal distension
; low intestinal obstruction : feculent emesis
- mod. or marked abdominal distension
- diffuse pain
Diagnosis
1. Hx. & P/Ex.
2. Laboratory study
; not diagnostic
; hypochloremic metabolic alkalosis
; marked leukocytosis /c or /s thrombocytopenia, metabolic acidosis, hematochezia
--> bowel infarction
; s-amylase & lipase
- R/O pancreatitis
3. Imaging
; plain simple abdomen (S+E) & lat.
- calcification in peritoneal cavity : meconium peritonitis
- ground glass appearance in RLQ with trapped air : meconium ileus
- normal child
/ Ãâ»ý Áï½Ã air in stomach
/ air within 1hr reach proximal portion of small bowel
/
*air in distal part of colon as
early as 3rd hr or as late as 18hr
; ultrasonography
; contrast studies
Management
; initial treatment
- fluid resuscitation and stabilizing
; nasogastric decompression
; broad spectrum antibiotics
; surgical repair
- strangulating infarctionÀÌ ÀǽɵǸé, Áï½Ã ¼ö¼ú
- medical Tx 12-24½Ã°£¿¡ improve¾øÀ» ¶§
276.1 Duodenal Obstruction
Duodenal Atresia
; incidence
- 1/1000
- 25-40% of all intestinal atresia
- 1/2 prematurity
; forms
1)
*membrane - ¡ãcommon
2) short fibrous cord connecting blind pouches
3) gap between non-connecting ends
; site - ampulla of vater Á÷ÇϺÎ
; µ¿¹ÝÁúȯ
-
*Down Syndrome (20-30%)
- malrotation (20%)
- esophageal atresia (10-20%)
- congenital heart disease (10-15%)
- anorectal and renal anomalies (5%)
Cause Of Duodenal Obstruction
1. atresia
2. incomplete rotation of midgut
3. annular pancreas
4. duodenal web(=windsock web)
- malrotation¸¹ÀÌ µ¿¹Ý
5. preduodenal portal vein compression
Clinical Manifestation
; *bilious
vomiting /s abdominal distension
- noted in 1st day of life
-
*hallmark
; visualed peristaltic waves
; Hx. of hydramniosis
; jaundice 1/3
; duodenal ileus
Diagnosis
; U/S in Utero
; plain abdomen
-
¡Ø92-92$
¡®double bubble sign¡¯ in erect view
- no gas below obstruction
; contrast studies
-
*usually not need
-
*occasionally exclude malrotation
& volvulus
Treatment
; Initial Treatment
- naso- or orogastric decompression & IV fluid replace
; asso. anomalies evaluation
- echocardiography, radiology
; surgical repair
- duodenoduodenostomy
- gastrostomy or jejunal tube to drain
- division & reposition in Ladd band with malrotation
/ balloon catheter·Î coexisting duodenal obstructionÀ» evaluation
- duodenoduodenostomy in annular pancrease
- duodenoplasty in duodenal diaphragmatic obstruction
276.2 Jejunal and Ileal Atresia and obstruction
# Etiology of jejunal and ileal obstruction
1) atresia & stenosis
2) meconium ileus
3) Hirschsprung disease
4) intussusception
5) Meckel's diverticulum
6) intestinal duplication
7) strangulated hernia
# Cause of jejunoileal atresia
;
*intrauterine vascular accidents
# Classification
type I (20%) ; intraluminal diaphragm(continuity is maintained)
II (35%) ; small diameter solid cord
IIIa(35%) ; blind loop with small mesenteric defects
IIIb ; extensive mesenteric defects and loss of normal blood, simply to the distal bowel "apple peel" appearance
IV ; multiple segment of bowel atresia
# Meconium Ileus
cystic fibrosis ÀÇ 10% ÀÌÇÏ¿¡¼ ¹ß»ý ( family Hx. )
last 20-30cm of ileum
:collapsed and filled with pellets of pale colored stools, impacted in the ileum
perforation½Ã meconium peritonitis
DDx with meconium plug SD(Lt. colon¹«Áõ»ó)
# Hirschsprung disease¿Í µ¿¹Ý 5%
: aganglionic segment°¡ entire colon°ú terminal ileum
Clinical Manifestation
abdominal distension and bile stained emesis : 1st day of life
fail to pass meconium : 60-75%
jaundice : 1/5-1/3
polyhydramnios(25%)
Diagnosis
U/S in Utero
Plain abdomen
1) meconium ileus
typical hazy or ground glass app. in RLQ with small bubble gas
mod. dilated bowel loop with air fluid level
2) meconium peritonitis
peritoneal calcification in flank
multiple air fluid levels
3) PneumomediastinumÀÇ ÀÇ½É ¼Ò°ß
¨ç 24½Ã°£³»¿¡ rapid abdominal distension
¨è liver percussion½Ã less dullness
¨é free fluid within abdomen 'foot-ball sign'
contrast studies
Treatment
fluid & E' balance & antibiotics
surgical repair laparotomy ileostomy colostomy
Gastograffin enema q 8-12 hr in meconium ileus(50%¼º°ø)
276.3 Malrotation
incomplete rotation of the intestine
°¡Àå ÈçÇÑ MalrotationÀº CecumÀÌ RLQ·Î move¾ÈµÇ¾î
1) volvulus
2) duo. obstruction by Ladd bands
#80 µ¿¹Ý Áúȯ
Non-rotation
1) Midgut volvulus
2) gastroschisis
3) omphalocele
4) Bochdalek hernia
Mal-rotation
1) annular pancreas
2) duo. atresia or stenosis
C/M
´ëºÎºÐ 1³â À̳», ¶§¶§·Î 1ÁÖ À̳»¿¡
volvulus : bilious emesis with acute bowel obstruction
recurrent abd. pain or vomiting in older
malabsorption or protein losing enteropathy
20-50% aSx.
Dx.
X-ray duo. obstruction : double bubble sign
Barium enema malposition of cecum(10%¿¡¼ Á¤»ó)
UGI : malposition of lig. Treitz
Tx.
surgical
fluid Tx.ÈÄ laparotomy
division of transduodenal bands
straightened LI in Lt. & SI in Rt. side abdomen
repair ÈÄ persistent Sx.½Ã
` Pseudo-obstruction-like motility disorder'
Chapter 277. Intestinal Duplications, Meckel's Diverticulum And Other Remnant Of The Omphalomesenteric Duct
277.1 Intestinal Duplication
; well-formed tubular or spherical structures
; mesenteric border¿¡ Á¸Àç
# Classification
1) localized duplication
2) duplications ass. with spinal cord defects & vertebral malformation
; hemivertebra, ant. spina bifida, connection between lesion and cervical thoracic spine
3) duplications of the colon
4) multiple duplications (10-15%)
# Site of localized duplications
1) *Ileum
; ¡ãcommon
2) Jejunum
3) Ileocecal region
4) Esophagus
# Neuroenteric cysts
; intrathoracic duplications of esophagus & stomach
; dysphagia & resp. Sx.¾ß±â
Pathology
1) Saccular type
; gastric mucosa lining(-), not communicated to bowel lumen, peptic ulcer(-)
2) tubular structure within the wall
;
*gastric mucosa lining(+),
communicated to bowel lumen
; *peptic ulcer, bleeding, perforation°¡´É
Clinical Manifestation
; infants¿Í early childhood¿¡ ÁÖ·Î ¹ß»ý
; depend on size, location, gastric mucosa lining
; bowel obstruction, lead point of intussusception, site of volvulus
; ulcer, perforation, bleeding, abd. pain, vomiting, palpable mass
; respiratory distress( neurogenic cyst )
; prolapse of rectum : diarrhea, constipation
Diagnosis
; Hx. & P/E
; barium studies
; U/S
; CT : intrathoracic lesion
; MRI : spinal cord lesion
; Radioisotope 99mTc scanning : ectopic gastric tissue
Treatment
; surgical repair
277.2 Meckel's Diverticulum and other Remnants of the
Omphalomesenteric Duct
; remnant of the embryonic yolk sac(=omphalomesenteric duct or vitelline duct)
; *2-3%
of all infants
; *¡ãcommon residual structure
; *¡ãfrequent congenital GI anomaly
Pathology
; 3-6cm outpouching along of ileum 50-75cm prox. to ileocecal junction on antimesenteric side
; ÃÖ¼Ò 35%¿¡¼ ectopic gastric or panc. tissue
Clinical Manifestation
; *usually
arise within 1st 2yr, common during 1st decade
; ¡Ø93$ painless rectal bleeding by ulceration of adjacent
normal ileal mucosa
- not neutrlized by pancreatic bicarbonate
; stool
- brick colored or currant jelly colored
; anemia
- self-limited because contraction of splanchnic vessels
; partial or complete obstruction
- by lead point of an intussusception
/
*¡ãcommon mechanism
- by intraperitoneal bands
--> internal herniation or volvulus
; diverticulitis
- similar to appendicitis
- perforation & peritonitis
Diagnosis
# ¡Ø82 99mTc Meckel radionuclide scan
;
*¡ãsensitive study
;
*enhanced scan by cimetidine,
glucagon, gastrin
-
*sensitivity 85%, specificity 95%
Treatment
; Complication
- hemorrhage
- diverticulitis -> perforation, peritonitis
- intussusception
- volvulus
- Littre hernia : indirect inguinal H. ¿¡ M. div. È£¹ß
; surgical excision
- choice
Chapter 278. Motility Disorders And Hirschsprung Disease
278.1 Chronic Intestinal Pseudo-obstruction
; anatomic lesion¾øÀÌ intestinal obstructionÀÇ Áõ»ó°ú ÁõÈĸ¦ º¸ÀÌ´Â Áúº´±º
; primary or secondary
; transiently or permanently
; Site
SI > colon > stomach > esophagus
Pathology
; wide spectrum from abnormal myoelectric activity to abnormalities of nerves(intestinal neuropathy) or musculature(intestinal myopathy)
; ¡Úcongenital
form
-
*spordically onset
-
*disorganized or hypo- or
hyperganglionosis
-
*outer longitudinal muscle layer
is replaced by fibrous material
Clinical Manifestation
; symptom *within
first few months of life
; *¼öÀϳ»¿¡
Áõ»ó º¸ÀÌ´Â
ȯ¾Æ
-
*2/3´Â prematureÀ̸ç, ¾à 40%´Â malrotation
; 75%´Â ù 1³â¿¡ °æÇè
; ¡Úabd.
distension & vomiting
-
*¡ãcommon (75%)
; constipation, failure to thrive, abd. pain (60%)
; diarrhea (30-40%)
; UTI (15%)
; urinary tract dilatation (30%)
; wax and wane symptom
Diagnosis
; anatomic obstructionÀÌ ¾øÀ¸¸é¼ compatible symptomeÀÌ ÀÖ¾î¾ß ÇÑ´Ù.
; plain abdominal X-ray
- air fluid level
- microcolon ( in neonate )
; contrast studies
- slow passage of barium
; gastrointestinal manometry
- involved intestine¿¡ µû¶ó abnormal motility patternÀ» º¸ÀδÙ.
-
*anorectal motility´Â
Á¤»óÀ» º¸¿© Hirschsprung diseae¿Í °¨º°ÇÒ
¼ö ÀÖ´Ù.
; radionuclide scan
- delayed gastric emptying
; exploratory laparotomy
-
*Áø´ÜÀ»
À§Çؼ´Â Çʿ䰡
¾ø´Ù. ¸¸¾à
½ÃÇàµÈ´Ù¸é, furture adhesive
obstruction with exacerbation of symptomsÀÇ °¡´É¼ºÀÌ
ÀÖ´Ù.
Differential Diagnosis
1. Hirschsprung Ds.
2. Other Causes Of Mech. Obst.
3. Psychogenic Constipation
4. Neurogenic Bladder
5. SMA Synd.
6. Hypothyroidism
7. Narcotics
8. Scleroderma
9. Chagas Ds.
10. Hypokalemia
11. Diabetic Neuropathy
12. Amyloidosis
13. Porphyria
Treatment
; *Nutritional
Support
-
¡Úmainstay of treatment
-
*30-50%´Â partial or complete pareteral nutrition
; prokinetic drugs
- cisapride(5-HT receptor antagonist)
-
*erythromycin(motilin receptor
angonist)
; oral AB for bacterial overgrowth
; Tx of constipation
- enema, suppositories, bowel softner
; Tx of peptic symptom
- acid suppressors
; surgery
-
*gastrostomy or placement of
jejunostomyÀ» Á¦¿ÜÇϰí´Â
µµ¿òÀÌ µÇÁö
¾Ê´Â´Ù.
-
*colectomy
/
*abnormalities°¡ colon¿¡¸¸ ±¹ÇѵǾîÀÖ´Â
°æ¿ì¿¡ °í·Á
; *bowel
transplantation or electromechanical pacing
278.2 Superior Mesenteric Artery Syndrome (Wilkies SD. Cast SD.
Arteriomesenteric Duodenal Compression Syndrome)
# ¢¾Definition
; extrinsic compression of the duodenum (2nd and 3rd portion) after weight loss (loss of supporting fat) and in supine position between SMA ant. and Aorta post. against spine
; classic description
-
*adolescent°¡
Á¤Çü¿Ü°ú ¼ö¼úÀ»
À§ÇÑ body castÈÄ vomiting ¹ß»ý
; asso. factors
- anorexia, prolonged bed rest, Wt. loss, abd. surgery, lumbar lordosis
Diagnosis
; plain abd. X-ray
- cutoff of the duodenum just to Rt. of the midline
- proximal duodenal and gastric dilatation
Treatment
; *positioning
in lat. & prone position
; Prokinetic agents
- Cisapride
; nasojejunal tube
; TPN
; surgical intervention
278.3 Congenital Aganglionic Megacolon (Hirschsprung Ds.)
; caused by abnormal innervation of bowel, beginning in internal anal sphincter & extending proximally
; *¡ãcommon cause of neonatal obstruction of colon
- all neonatal obst. ÀÇ 33%
; *male
: female = 4 : 1
; incidence 1/5,000
; associated congenital defects
1. 21-Trisomy
2. Laurence-Moon-Biedl-Barat Synd.
3. Waardenburg Synd. & Megasystis - Megaureter
4. Cardiovascular abnormalities
; premature infant : rare, familial incidence ( 4-8% ) : °¡²û
Pathology
; arrest of neuroblastoma migration from proximal to distal
--> absence of ganglion cells
--> increase nerve ending in aganglionic bowel
--> high concentration of acetylcholinesterase
; *absence
of Meissner and Auerbach plexus and hypertrophied nerve bundle with high
concentration of acetylcholinesterase between muscular layer and submucosa
; *knockout
of endothelin B receptors
; involved lesion
-
*rectosigmoid (75%)
- anus to hepatic flexure ±îÁöÀÇ colon (15%)
- entire colon (10%)
Clinical Manifestation
; usually begin at birth with delayed passage
- noraml meconium passage
/ 99% of fullterm within 48hr
- some infant´Â Á¤»óÀûÀ¸·Î meconium passageÈÄ chronic constipationÀ» º¸À̱⵵ ÇÑ´Ù.
; vomiting, abd. distention
--> decreased blood flow
--> bacterial overgrowth
- enterocolitis by Cl. difficile, Sta. aureus, anaerobes, coliforms
-
*enteroclitis ¹ß»ý
Àü¿¡ ¹ß°ßÇØ¾ß morbidity & mortality°¨¼Ò
; failure to thrive with hypopreteinemia from protein-losing enteropathy
; *palpable
large fecal mass in LLQ but empty in rectum
; BMF´ÂWMFº¸´Ù not severe
¡ÚTable
278-1 DDx of Hirschsprung diseae and functionl constipation
# ¢¾DDx In
Infancy
; small left colon synd. in infant of DM mother
; meconium plug synd.
; ileal atresia with microcolon
; malabsorption synd
Diagnosis
# Rectal manometry and rectal suction biopsy
;
*¡ãreliable indicators
# Rectal manometry
; measures pressure of internal anal sphincter muscle while balloon is distended in rectum
; normal
- reflex drop in internal sphincter muscle pressure
; patients
-
*fail to drop or paradoxical rise
in internal sphincter muscle pressure
;
*normal À̸é exclude Hirschsprung disease, but equivocal or paradoxical
responseÀ̸é punch or suction
biopsy
-
¡Ø96½Å»ý¾Æ¿¡¼ false positive
-
dentate line 2cmÀ̳»¿¡¼´Â
½ÃÇàÇÏÁö ¾Ê´Â´Ù.
; *more than 90% accuracy
# X-ray
; presence of transitional zone
- not usually present before 1 to 2wks
;
¡Ø96
without prepration to prevent transient dilatation
;
*barium enema´Â
Áø´Ü ¸ñÀû
º¸´Ù´Â evaluating other
diseae & determining extent°¡ ´õ
ÀÇÀǰ¡ ÀÖ´Ù.
; 24hr delayed film more helpful
- significant barium
# ¡ØÁÖ Barium Enema¼Ò°ß
; abrupt caliber change between gang. & agang. section of bowel
; irregular sawtooth contractions of agang. seg.
; parallel transverse folds in dilated prox. colon
; thickened, nodular, edematous prox. colon ass. with protein-losing enteropathy
; failure to evaduate barium
# ¡Ø82,83 Classic Feature Àß
¾Èº¸ÀÌ´Â °æ¿ì
; newborn
- prox. colon°ú distal agang. colon»çÀÌÀÇ size disparity ³ªÅ¸³¾ ½Ã°£Àû ¿©À¯ ºÎÁ·
; entire colon
; ultrashort segment
Treatment
; operative intervention
; limited laparotomy with multiple biopsy with colostomy in most distal portion of normal gangl. colon
; temporary colostomy and then definite repair at 6-12 mo
- three surgical options
¨ç Swenson
/ anastomose normal proximal bowel to retum 1-2cm above the dentate line
¨è Duhamel
/ create neorectum
/ anterior agnaglionic half with normal sensation & posterior ganglionic half with normal propulsion
¨é Boley
/ endorectal pull-through procedure
# ultrashort segment
; limited to internal sphicters
; normal rectal suction biopsy but abnormal rectal motility
; internal sphicter muscleÀ» Æ÷ÇÔÇÑ biopsy
# total colon aganglionosis
; ileal-anal anastomosis with preserving agang. colon
; Duhemel op.
Prognosis
; generally satisfactory for fecal continence
; early colostomy ½Ã mortality 4%
; enterocolitis ÈÄ mortality 33%
Chapter 279. Ileus, Adhesion, Intussusception, And Closed Loop Obstruction
279.1 Ileus
; failure of intestinal peristalsis without evidence of mechanical obstruction
¡ÚEtiology
1.
abd. surgery - *¡ãcommon
2. infection, (Pn., AGE, peritonitis)
3. metabolic abn. (uremia, hypikalemia, acidosis)
4. drugs(*vincristine, loperamide)
Clinical Manifestation
; increasing abd. distension
; abd. pain initially minimal
Diagnosis
; plain abd.
- multiple air fluid level thoughout the abdomen
; contrast radiography
- slow movement of barium through the patent lumen
Treatment
; correction of underlying causes
; nasogastric decompression
; prokinetics
- cisapride, erythromycin
279.2 Adhesion
fibrous bands
post. op. SI obstruction after abd. surgery : 2-3%
single after 2 weeks
Clinical Manifestation
pain & distension nausea vomiting
fever & leukocytosis : necrotic bowel and peritonitis
Diagnosis
P/E bowel sound hyperactive and abdomen flat initially
then, bowel sound disappear and abdomen distension
Plain abd.
contrast radiography
Treatment
nasogastric decompression
IV fluid resucitation
Broad spectrum antibiotics
surgical intervention
279.3 Intussusception
; Incedence 1-4/1,000
; M:F=4:1
; *¡ãcommon intestinal obstion between 3mo and 6yr
-
*rare in younger than 3mo,
decrease in frequency after 36mo
Etiology & Epidermiology
; unknown
; seasonal incidence
-
*peaks in spring & autumn
; correlation with adenovirus infection
# Lead Points
-
*more common in very young and
older patients
- 5-10%
-
*inverted appendiceal stump,
Meckel's diverticulum, intestinal polyp, duplication, lymphosarcoma
- uncommonly
/ H-S purpura with intramural hematoma
- rare
/ *post. op.(always ileoileal), dehydrated patients with cystic fibrosis, metastatic tumor, hemangioma, foreign body, parasitic infection, fecolith, after cancer chemotherapy
Pathology
# Site
1. ileocolic & ileoilecolic ; *¡ãoften
2. cecocolic
3. ileal
# intussusceptum
; upper portion of bowel, invaginated into the lower
;
*dragging its mesentery along with
it into the enveloping loop
# intussuscipiens
; lower portion of bowel
# *after
24hr
;
*intestinal gangrene and shock
Clinical Manifestation
; sudden onset of severe paroxysmal coliky pain in previously well child
; initially maybe comfortable and play normally between paroxysm of pain
--> progressively weaker and lethargic
--> moaning sound
--> shock like state
/ fever, weak and thready pulse, respiration shallow and grunting
; vomiting
- more frequent early
; stool
- normal during 1st few hr of symptom
-
*blood in first 12hr (= current
jelly stool (60%))
/ infrequently not at all
; *sl.
tender saussage mass(70%)
- increase size & firmness during paroxysm of pain
-
*¡ãoften in RUQ & long axis cephalocaudal
- if felt in epigastrium
/ long axis or transverse
-
*30% not palpable
; abd. distension & tenderness
- more acute
; ileoileal intussusception
- less typical Sx
- SI obstruction Sx. Sn.
; *recurrent
intussusception
-
*5-8%
-
*more common following hydrosttic
than surgical reduction
; chronic intussusception
- symptom exist in milder form at recurrent interval
- following acute enteritis
- older children
Diagnosis
1. clinical Hx. & P/E
2. plain abd.
; mass density
3. barium enema
; *filling defect or cupping in the head of barium
;
*coiled-spring sign
; *ileoieal intussusceptionÀº Áø´ÜÀÌ
µÇÁö ¾Ê°í, Plain abdomen»ó
lesionÀ§ÂÊÀ¸·Î gaseous distensionÀ¸·Î
ÀǽÉÇϴ¼ö ¹Û¿¡
¾ø´Ù.
4. air enema
; Dx. & Tx.
;
*safer with less risk of
perforation
; as accurate as barium enema
; less irradiation
5. real time sonography
; useful Dx.
; target or donut configuration of bowel
- hypoechoic rim & dense central echogenic core
-
*rim thickness 0.6 cm¡è
- *rim thickness 1.6 cm ÀÌ»ó½Ã ¼ö¼ú ÇÊ¿ä
Differential Diagnosis
1. gastroenteritis
2. enterocolitis
3. Meckel's diverticulum
4. anaphylactoid purpura
Treatment
; reductionÀÌ emergency procedure
- after diagnosis & rapid preparation for operation with fluid & blood for shock and water & electrolyte to replace losses
; hydrostatic or pneumatic pressure under fluoroscopic or ultrasonographic guidence with consultation and close proximity of surgeon
; more than 74% of cases
- short duration
- no sign of prostration, shock, peritoneal irritation, pneumatosis intestinalis
¡Ø92ÁÖ Reduction Findings Of
Intussusception
; free filling of small intestine
; disappearance of mass
; passage of flatus or feces
; improvement of infant's condition
# ¢¾Surgical
Indication
; prolonged intestinal obstruction with peritonitis
; ileoileal type
Prognosis
; 24½Ã°£ À̳»´Â recover
; 2ÀÏ ÀÌÈÄ´Â mortalityÁõ°¡
; spontaneous reduction during preparation for op.
; unTx.½Ã °ÅÀÇ fatal
; ¡ÚRecurrence Rate
- after barium enema : 10%
- surgery (manual) ; 2-5%
- resection : 0%
; *lymphosarcoma,
polyp, meckel's diverticulum´Â barium enema¿¡
ÀÇÇÑ reductionÀÌ
°ÅÀÇ ¾ÈµÈ´Ù.
279.4 Closed loop Obstruction
defects in the mesentery ( internal hernia )¸¦ ÅëÇØ SI loop°¡ pass & trap
vascular engorgement of trapped bowel ,intestinal ischemia & gangrene
C/M
transient or recurrent or spontaneous relieve
bilious vomiting
abd. distension, abd. pain
peritoneal sign : bowel ischemia
Dx. plain rad. sign of small bowel obstruction
free air : perforation
Tx. : prompt surgical relief
CHAPTER 280. Foreign Bodies
and Bezoars
280.1 Foreign Bodies in the stomach and intestine
peak incidence 6Mo-3yrs
Á¾·ù
1. young children : coin
2. older children : fish or chicken bone
risk factor
1. after alcohol consumption or cold liquid
2. psychiatrically impaired pt.
outcome
80-90% spontaneous pass (º¸Åë 4-6ÀÏ, ¶Ç´Â 3-4ÁÖ)
10-20% endoscopic removal or conservative Tx.
1% or less surgical intervention
1% or less perforation
site : physiologic sphincters
acute angulation
congenital gut malformation
previous bowel surgery
Dx. plain rad.(chest X-ray Æ÷ÇÔ) & contrast rad.
Tx. regular diet
endoscopic removal
1. older children : > 5cm in diameter, 2cm in chickeness, 10cm in length
2. infants : > 20mm in diameter, 3cm in length
3. needle, hair, pin, hobby pin, open safety pin
surgery : perforation sign
laxatives : CIx. (intestinal motilityÁõ°¡·Î perforationÁõ°¡)
280.2 Bezoars
accumulation of exogenous matter in the stomach or intestine
most in female, 2nd decade, with underlying personality problem
or neurologically impaired
trichobezoars( hairs ), phytobezoars( plants & animal )
lactobezoars( casein or calcium in premature )
C/M
Sx. of gastric outlet or partial intestinal obstruction sign,
vomiting, anorexia, Wt. loss, abd. pain or distension halitosis
µ¿¹ÝÁúȯ : chr. gastritis, IDA, hypoproteinemia, steatorrhea
Dx.
P/E : patchy baldness and a firm mass in LUQ
plain or contrast rad. or ultra
endoscopy
Tx.
endoscopic disruption or removal
surgical intervention
lactobezoars : 24-48½Ã°£ feedingÇϸé resolve
Chapter 281 Anorectal Malformations
Incidence 1/4,000
Embryology & Pathogenesis
; origin cloaca
Pathology And Classification
Male
Perineal Fistula
; ¡ãsimplest defect in both sexes
; bucket-handle type malformation or blck ribbon type stucture in perineum
; well-formed sacrum
; affecting other organ - 10%
;
*repaired without protective
colostomy
Rectourethral Fistula
;
*¡ãfrequent anorectal defect in male patients
; flat-looking perineum
; hypodevelopmental sacrum
; protective colostomy during newborn periods
Rectovesical Fistula
; poorly developed sphincteric mechnism
; flat-looking perineum
; poor prognosis of bowel function
; mandatory colostomy
Imperforate Anus Without Fistula
; blind retal loop 2cm above perineal skin
;
*well-developed sacrum,
sphincteric mechanism
; good functional prognosis
;
*ass. with down syndrome
Rectal Atresia
; normal anus & anal cannal
; obstruction 2cm above perineal skin
; good functional prognosis
; protective colostomy
Female
Vestibular Fistula
;
*¡ãfrequent defect in females
; normal sacrum
; excellent prognosis
Persistent Cloaca
; fuse into single common channel
; short common channel(<3cm)
- well-developed sacrums & good sphincters
; longer than *3cm channel
- more complex defect
- poor sphincteric mechanism & poor sacrum
- hydrocolpos
-
*diverting colostomy
-
*90% urologic defect
/
*colostomyÀü
¹Ýµå½Ã urinary evaluation
|
No colostomy |
Colostomy |
Males |
Perineal Fistula |
Rectourethral Fistula Rectovesical Fistula Imperforated Anus without Fistula Rectal Atresia |
Females |
Perineal Fistula |
Vestibular Fistula Persistent Cloaca Imperforated Anus without Fistula Rectal Atresia |
Diagnosis & Early Management
#
¢¾¡ãImportant Decision Regarding Newborn With Anorectal
Malformation
; whether needs diverting-decompression colostomy and emergency urinary diversion for associated obstructed uropathy
Males
; perineal or rectourinary fistula´Â 16-24hrÀ̳»¿¡ meconiumÀÌ passµÇ±â¶§¹®¿¡ Áø´ÜÇÏ±â ¾î·Æ´Ù.
; gauze test
; clinical sign(+)À̸é 24hr observation
- and then radiologic evaluation
/ *cross-table lateral film in prone position for determining position of rectal pouch
-->
*skinÀ¸·ÎºÎÅÍ 1cmÀÌ»óÀ̸é colostomy
;
*all patients need abdominal
ultrasound evaluation
Females
; meticulous perineal inspection : 90%
; single perineal orifice or palpable pelvis mass
- persistent cloaca
Associated Defects
;
*50% of children with anorectal
anomalies
;
¡ÚUrologic Problem
- *90% ÀÌ»ó : male rectovesical
fistula and persistent cloaca
- 10% ÀÌÇÏ : rectoperineal fistula
-
*evaluation before performing a
colostomy
;
*good correlation between degree
of sacral development and final functional prognosis
; spinal or sacral abn., esophageal or duodenal atresia, cardiovascular defects
Treatment
; perineal fistula : anoplasty without protective colostomy during infant
; other fistula
- protective colostomy during infant
- corrective surgical repair, later in life (1-12mo)
; posterior sagittal approach
- uses an electric muscle stimulator to idendify the sphincteric mechanism
- direct exposure to internal anatomy
- avoid potential damage to important sturcture and nerves
Prognosis
; perineal fistula & rectal atresia : good
; males rectourethral bulbar F. : 80% bowel control, 3-4yrs
; both sexes imperforated anus without fistula : same above
; male rectourethral prostatic F. : 60% bowel control, 3yrs
; *male
rectovesical fistula : 20% bowel control, 3yrs
; female rectovestibular F. : 90% bowel control, 3yrs
; persistent cloaca with common channel (<3cm) : 80% bowel control, 3yrs
; *
"
"
" (>3cm)
: most fecal incontinence
Complication
; fecal or urinary incontinence
; constipation
-
*more severe in lower and simpler
defects
Chapter 282. Ulcer Disease
; uncommon in children
-
¡Ø93 2¼¼ÀÌÀü DU=GU
- 2¼¼ÀÌÈÄ DU>GU
Pathology And Physiology
# ¡ÚPredisposing
Factors
1. gastric acidity DU(high) GU (nl or low)
2. blood type O
3. high serum pepsinogen I
4. genetic factor
; family Hx in duodenal ulcer (25-50%)
; concordance for duodenal ulcer in monozygotic twin (50%)
5. cigarette smoking
6. climatic condition
7. diet(alcohol)
8. emotional strain
9. tissue resistance
; cell turnover, mucus production, bicarbonate secretion, local PG synthesis, tissue assult
; factors lowing resistance
- anoxia, poor perfusion, bile and drugs (esp, NSAID)
10. Helicobacter pylori
; present in gastric mucosa
; cause chronic lymphonodular gastritis
; eradication of H. pylori
- asso. with healing & lone-term cure of recurrent peptic ulcer
# Pathology
; superficial abrasion, deep erosion, penetraion, hemorrhage, perforation
; abrasion
- 1cm ro less in diameter
- fibrinus coat of leukocyte & red cell cover fibrinoid necrosis surround by inflammatory cells
; acute or chronic gastric obstruction
;
¡Ø93
Sites
DU : post. part of bulb
GU : lesser curve or antral area
282.1 Primary (Peptic) Ulcers
; ¡Úusually
chronic, duodenal, related to H. pylori
Clinical Manifestation
; variable & non-specific
; vomiting, G-I blood loss, pain, familial incidence
# 1st 1 mo
; ¡Ø93 2 most common Sx.
- GI hemorrhage
- perforation
# neonate - 2yr
;
*recurrent vomiting, slow growth,
GI hemorrhage
# preschool age
; *periumbilical postprandial pain
- often elicited
; vomiting, hemorrhage
# 6 yr¡è
; adult¿Í À¯»ç
; epigastric abdominal pain, acute or chr. GI blood loss(hematemesis, hematochezia, melena)
; IDA
; *male ¡è
; strong family Hx.
; characteristics of pain
- dull or aching than sharp or buring as adult
- last from minutes to hours
- frequent exacerbation and remission lasting from weeks to months
- common nocturnal pain
;
*history of typical ulcer pain
with relief after taking antacids
-
*33%
Diagnosis
# UGI
;
acute Sx.ÀÌ ¾Æ´Ñ
°æ¿ì, *most
useful available test
;
*DU 75%, GU 0% detect
; true deformity of bulb -> past uler ds.ÀÇ good sg.
; spasm of bulb´Â normal
; DDx
- duodenitis, irritability of bulb, pylorospasm
# ¡Ø93 Gastroduodenoscopy
; Indication
- X-ray»ó questionable or absent in Sx. pt.
- X-ray»ó healing µÇ¾ú¾îµµ Sx. Áö¼Ó
- ulcer craterÀÇ prolonged presence
- acute UGI bleeding½Ã blood clotÁ¦°ÅÇÒ ¼ö ÀÖ´Ù¸é choice
# Selective Abdominal Angiogram
; active, severe UGI bleeding½Ã -> vasoconst. agent of embolization
# Gastric Acid Analysis
; recurrent severe ulcer or multiple ulcer½Ã
; gastrin level check for Z-E synd.
Differential Diagnosis
; esophagitis, giardiasis, GE reflux, Meckel's diverticulum, pancreatitis, inflammatory bowel ds. cholelithiasis, appendicitis, recurrent abdominal pain of childhood
Treatment
# Goal Of Therapy
i) healing of ulcer ÃËÁø
ii) relieve pain
iii) prevent Cx.
# Recurrence
; 6¼¼ÀÌÇÏ 25%, 6¼¼ÀÌ»ó 70%
1. normal diet
; aspirin, alcohol, smoking±ÝÁö
; bland diet, cola, coffee, spiced foodÀÇ ±ÝÁö°¡ healingÃËÁø½ÃŰÁö´Â ¾ÊÀ½.
2. antacid .... mainstay
;
*liquid form > tablet
; full-dose
- 100mEq of stomach acidity/m2 ÁßÈÇÏ´Â 15ml/ dose antacid
-
*¼Ò¾Æ
¿ë·® : 1ml/kg/dose
;
*1-3hr after a meal & at
bedtime
-
*¡ãeffective
; bed time snack ±ÝÁö
; therapy for : 4-6 wk
; side effect
- Mg
/ diarrhea
- aluminum
/ constipation
/
*phosphate deletion & aluminum
toxicity
: dietary phosphate¿Í bindÇÏ¿© PÀÇ Èí¼ö Àå¾Ö·Î ÀÎÇØ ¹ß»ý
:
*anorexia, osteomalacia,
osteoporosis
- calcium antacid
/ buffering effect ³¡³ÈÄ acidºÐºñ Áõ°¡
- NaHCO3
/ chr. use ½Ã systemic alkali, Na load
3. H2 antagonist
; 12¼¼ ¡è
; single dose at night -> recur ¿¹¹æ
; cimetidine : (20-40 mg/Kg/day #4) meal time, bed time
; ranitidine : (4-6 mg/Kg/day #2)
4. sucralfate : local coating action
5. omperazole
;
*potent H+-K+ ATPase pump
inhibition
; single dose in delayed released capsule
5. anticholinergic drug
; gastric acid secretion inhibit
;
*dry mouth, blurred vision ³ª¿Ã
¶§±îÁö high dose ÇÊ¿äÇϹǷΠfirst therapy·Î´Â ºÎÀûÀý
6. ¡Ø96ÁÖ Tx.
for H. pylori
;
*not responding to therapy and
recurrent diseaseÀÏ °æ¿ì H. pylori¿¡ ´ëÇÑ
°Ë»ç ¿ä
;
*Amoxicilin, metronidazole,
bismuth for 2wks
7. Surgery
;
¡ÚIndication
- perforation
- intractable pain or chronic bleeding
- embolizationÀ̳ª cautery·Î Á¶ÀýµÇÁö ¾Ê´Â blood loss more than 30% within 48hr from hemorrhage
- nasogastric drainage·Î 72½Ã°£³» È£ÀüµÇÁö¾Ê´Â gastric outlet obstruction
; vagotomy + pyloroplasty
282.2 Secondary Ulcers
; *primary
ulcerº¸´Ù 2¹è
ÀÌ»ó
Stress Ulcers
; often multiple, ass. with hemorrhage gastritis
; Causes
1.
infants : *sepsis, resp. or cardiac
insufficiency or dehydration
2. older children : trauma, life threating condition
3. Curling ulcer : burn (13%)
4. Cushing ulcer : head trauma, surgery
; perforation or acute massive painless bleeding
- often initial symptom
Drug-related Ulcer
;Aspirin or NSAID(25%), alcohol and smoking, steroid
Treatment
; similar to primary U.
; maintaining gastric pH > *3.5
; *Misoprostol
- PG analog
-
*prevent delvelopment of gastric
ulcers in chronically taking NSAID
282.3. Zollinger-Ellison Syndrome
; multiple recurrent duodenal & jejunal ulcers
; gastric secretion ¡è & hypertrophy of gastric fold on X-ray, diarrhea
; islet cell tumor or hypertrophy -> ¡è¡è gastrin (-> acid¡è)
; Treatment
- chronic cimetidine therapy or omperazole
- gastrectomy
CHAPTER 283. Inflammatory Bowel Disease
; unpredictable exacerbations and redission
; dimodal distribution
- 15~25yr, 50~80yr
-
*¡ãcommon during adolescence and young adult
; genetic & environmental components
-
*asso. genetic disorders
/ Turner syndrome, Hermansky-Pudlak syndrome, glycogen storage disease type Ib, immunodeficiency disorders
; DDx of CD & UC
- clinical, radiologic, endoscopic, histopathologic findingsÀ» Á¾ÇÕÇÏ¿© Áø´Ü
- 10%´Â Á¤È®È÷ Áø´ÜÇÏÁö ¸øÇÑ´Ù.
- Ä¡·á¿¡ ÀÖ¾î °øÅëÀûÀÎ ºÎºÐµµ ÀÖÁö¸¸ refinements¿¡ ÀÖ¾î Â÷À̰¡ ÀÖ¾î ±¸ºÐÀÌ Áß¿äÇÏ´Ù.
; extraintestinal manifestation
-
*more common in CD
-
*peripheral arthritis, erythma
nodosum, anemia´Â bowel diseaseÀÇ activity¿Í ¿¬°ü¼º
- pyoderma gangrenosumµµ bowel diseaseÀÇ activity¿Í ¾à°£ÀÇ ¿¬°ü¼º
- arthritis
/ three pattern
: migratory peripheral arthritis involving primarily large joints
: ankylosing spndylitis
: sacroiliitis
/
*peripheral arthritis´Â nondesturctive
- skin manifestation
/
*erythma nodosumÀÌ
¡ãcommon lesion
/ erythma nodosum, pyoderma gangrenosum˼ high likehood of having arthritis
- glomerulonephritis, hypercoagulable state, cerebral thromboembolism, uveitis
/ common in childhood
283.1 Chronic Ulcerative Colitis
; colonic mucosa¿¡ ±¹Çѵǰí UGI´Â sparingµÇ´Â idiopathic chr. inflammatory disorder
; always begins in the rectum
; ulcerative proctitis - localized in rectum
; 20-50% of UC
- less systemic mani. & less response to Tx.
; pancolitis
- involving entire colon
Etiology
; unknown
; immunologically mediated Rx.À¸·Î »ý°¢
Incidence
; 1/10,000( Japan, South Africa) 15/10,000( northern Europe, USA )
; *male
slightly more frequent
Clinical Manifestation
; insidious onset with gradual progression or fulminant course
; mild dysentery (bloody diarrhea with mucus)
-
*¡ãtypical presentation
; tenesmus, urgency, crampy abd. pain(esp. with bowel movement), nocturnal bowel movement
- more severe colitis¸¦ ÀǹÌ
; *fever,
anemia, hypoalbuminemia, leukocytosis, stool frequency (>6/day)
-
*fulminant colitis¸¦
ÀǹÌ
; chronicity( > 3-4 wks)°¡ Áø´Ü¿¡ Áß¿äÇÑ ¿ªÇÒ
; anorexia, wt. loss, growth failure (more typical in Crohn diasease)
; ¡Úmore
common extraintestinal symptom than CD
- pyoderma gangrenosum (necrotic skin lesion), sclerosing cholangitis, CAH, ankylosing spondylitis
; IDA
- chronic blood loss·Î ¹ß»ý
; folate deficiency
-
*sulfasalazineÀ¸·Î
Ä¡·áÇϴ ȯ¾Æ¿¡¼
ÈçÇÔ.
- folate Èí¼ö¸¦ ¹æÇØÇϱ⠶§¹®.
; clinical course
- exacerbtions often without apparent explanation
; colon cancer risk
-
*increase 8-10yr of disease and then
increase by 0.5-1% per year
- childhood onset not increase risk further
- Prevention
/
¡Ú10yr durationÈÄ¿¡´Â
biopsy every 1-2yr
Differential Diagnosis
; infectious colitis, crohn disease
¢ÞTable
283-1 Comparison of crohn disease and ulcerative colitis
¡ÚTable
283-2 Infectious agents mimicking inflammatory bowel disease
; colitis of HUS, Behcet syndrome, cathartic colitis, radiation procitis, human immunodeficiency virus-associated colitis, ischemic colitis, protein intolerance
Diagnosis
; not confirm test
; typical presentation in bsence of identifiable specific causes
; chronicity - 3-4 wks
- firm diagnosis
; laboratory finding
- anemia, hypoalbuminemia
- elevated ESR
/ maybe normal even with fulminant colitis
- leukocytosis
/ only seen with more severe colitis
-
*antineutrophil cytoplasmic
antibodies
/
*65% of UC, 20% of CD
# Endoscopic examination
; more sensitive for mild disease
; typical features
- concentric, diffuse colitis starting in rectum & extending proximally for variable distance
- no skip area
; colonoscopic exam
- fulminant caseÀÎ °æ¿ì¿¡´Â ±Ý±âÀÌ´Ù.
- microulcers giving appearance of diffuse abnormality
/ ulcer°¡ ¾ø´Â °æ¿ì¿¡´Â CDÀÏ °æ¿ì°¡ ³ô´Ù.
-
*earlist : granularity and loss of
nl. vascularity
- severe change : spontaneous friability, erythema, edema of mucosa, blunting of mucosal fold
-
*very severe change : pseudopolyp
# perianal disease or anal fissures with diarrhea´Â CDÀÇ °¡´É¼ºÀÌ ´õ ³ô´Ù.
# Biopsy
; acute and chronic mucosal inflammation
; typical findings
- cryptitis, crypt abscess, separation of crypt by inflammation cell, foci of acute inflammatory cell, edema, mucous depletion, brancing of crypts
# Plain Abdomen
; loss of haustral markings in air-filled colon, marked dilatation with toxic megacolon(>6cm in diameter)
# Barium enema
; diffuse, concentric disease with finely spiculated border
--> microulceration
; earlies change - fine granularity followed by more coarse granularity
--> progressing severe disease
-
*¡®collar button ulcers¡¯
; thickened mucosal folds, completely obliterated to give smooth-appearing surface
-
*¡°lead pipe colon¡±
- reversible with treatment
; normal terminal ileum
- except) pancolitis
/
*dilated terminal ileum with
patulous ileocecal valve : ¡°backwash ileitis¡±
Treatment
# aim
1) control Sx.
2) reduce risk of recurrence
# spontaneous improvement in Sx. : 20-30%
# ¡Ø96 Drug Medication
; mild colitis¶§ »ç¿ë.
1) aminosalicylate
- sulfasalazine 50-75mg/Kg/day #2-4, no more than 2 or 3g/day
/ sulfur moiety°¡ active ingredient 5-aminosalicylate¿Í ¿¬°üµÇ¾î ÀÖ¾î ¼ÒÀå¿¡¼´Â Èí¼öµÇÁö ¾Ê°í, ´ëÀå¿¡ À̸£·¯ bacteria¿¡ ÀÇÇØ 2°³ÀÇ components·Î ºÐ¸® µÈ´Ù.
/
*Á¡Â÷·Î
¿ë·®À» Áõ·®ÇÏ¿©
Ä¡·á 1ÁÖ°æ¿¡ full-dose
/ remissionÀÌ »ý±â´õ¶óµµ °è¼Ó »ç¿ë
/
*only drug shown to prevent
relapses
/ Side Effects
:
*hypersensitivity, skin
rash(typically morbiliform), hepatopathy, fever, exfoliative
dermatitis(stevens-Johns syndrome)
: others - reversible leukopenia, hemolysis, pancreatitis, headache, nausea & vomiting, bloody diarrhea
: bloody diarrhea ´Â disease progression°ú DDx °¡ ¾î·Æ´Ù.
- olsalazine
/ sulfasalazine¿¡ side effectÀ» °¡Áø ȯ¾ÆÀÇ 10-20%´Â ´Ù¸¥ 5-aminosalicylate¿¡µµ ¿ª½Ã side effectÀ» ³ªÅ¸³½´Ù.
/ diarrhea°¡ common side effect
2) Hydrocortisone enemas
- 100mg once a day for 2-3wks
3) Corticosteroids
-
*severe pancolitisÀ̰ųª 5-aminosalicylate¿¡ ¹ÝÀÀÇÏÁö
¾Ê´Â °æ¿ì
- prednisone 1-2mg/Kg/day (below 40mg) for 3-4mo
/
*not severe symptomÀÎ
°æ¿ì¿¡´Â single morning dose·Î
»ç¿ëÇϰí, severe colitisÀ̸é, daily divided dose ·Î »ç¿ëÇÑ´Ù.
/ *1-3mo³»¿¡ alternate-day dose·Î ¹Ù²Û´Ù.
- Side Effects
/ growth retardation, adrenal suppression, cataracts, aseptic necrosis of femoral head, DM, risk of infection, cosmetic effects
4) azthioprine, 6-MP, metronidazole, cyclosporine
# ¢¾Surgical
Therapy
1) Steroid Ä¡·á¿¡ ¹ÝÀÀÀ» ÇÏÁö ¾Ê°Å³ª dependentÀÎ °æ¿ì
2) fulminant disease
; 3-4wks°£ÀÇ Ä¡·á¿¡ ºÒ±¸Çϰí, ¹ÝÀÀÀ» ÇÏÁö ¾Ê´Â °æ¿ì
; > 6-8 stool/day, passage of stools during night, fever, leukocytosis, anemia, hypoalbunminemia
Prognosis
; *remission
and exacerbation
; *´ëºÎºÐÀÇ
ȯ¾Æ°¡ Ãʱâ medical management ¿¡ Àß
¹ÝÀÀÇÑ´Ù.
; risk of colon cancer
- after 8-10 yrs, 0.5-1% /yrs
- proctitis alone¿¡¼´Â ¹ß»ý¾ÊÀ¸¸ç, mucosal dysplasia°ÅÃÄ ¹ß»ý
- 10³â ÀÌÈÄ¿¡´Â ¸Å 1-2³â¸¶´Ù colonoscopy¿Í biopsy½ÃÇà
; toxic megacolon
- most serious acute Cx.
- impending perforation sign
283.2 Crohn Disease (=Regional Enteritis, Regional Ileitis,
Granulomaous Colitis)
; Mouth¿¡¼ Anus±îÁöÀÇ À§Àå°üÀÇ idiopathic chr. inflammatory disorder
- eccentric & segmental with skip area
- transmural gastrointestinal involvemnent
; site
- initial ileum & colon
/ ileocolitis
/
*¡ãcommon
- small bowel alone
/ terminal ileitis
/ 50%
- colon alone
/ granulomatous colitis
/ 10%
Incidence
; rare in 1st 10 year of life
; bimodal age distribution
- 1st peak beginning late teens
; *°ú°Å 10³âµ¿¾È ºóµµ°¡
Áõ°¡Çϰí ÀÖÁö¸¸, UC´Â stable
; 3-4/100,000
; prevalence 30-100/100,000
Clinical Manifestation
# Region of Bowel Involved, Degree of Inflammation, Presence of Complication(Stricture Or Fistular)¿¡ µû¶ó Áõ»óÀÌ ´Ù¸£´Ù.
; ileocolitis
- crampy abd. pain, diarrhea sometimes with blood
; ileitis
- RLQ abd. pain alone
; colitis
- bloody diarrhea, tenesmus, urgency
; gastric or duodenal involve
- recurrent vomiting, epigastric pain
; partial SI obstruction Sx.
- crampy abd. pain, borborygmi, abd. distension
- sudden gurgling of intestinal contentsÈÄ symptom relief°¡ ÀÖÀ¸¸é, strictureÀǽÉ
; ureteral obstruction Sx.
# *Systemic
Manifestations
; more common than UC
;
*fever, malaise, fatigability,
growth failure delayed sexual development, amenorrhea
# perianal disease
; more common than UC
; tags, fistula, abscess
# fistula
; enteroenteric, enterocolonic, enterovesical, enterovaginal, enterocutaneous, perianal
# intraabd. abscess
; hepatic, splenic, psoas, anorectal, perianal
# *Extraintestinal
Sx
; more common than UC
; oral aphthous ulcer, peripheral arthritis, erythema nodosum, digital clubbing, episcleritis, renal, GB stone
;
*correlates with presence of
colitis
# short bowel syndrome
; bile acid malabsorption with steatorrhea, Vit. B12 malabsorption
; chronic steatorrhea --> oxaluria with secondary renal stones
; bile acid depletion --> cholelithiasis
Differential Diagnosis
¡ÚTable
283-3 Chronic Inflammatory Intestinal Disorders
Diagnosis
; typical clinical features, ruling out specific entities that mimic Crohn disase, demonstrating chronicity (1-2yr)
- commonly weight loss
- linear growth retardationÀÌ 1-2³âÁ¤µµ ¸ÕÀú ¹ß»ýÇØ¾ß ÇÑ´Ù.
- pale, decreased energy level, poor appetite
/ latter findings
# Laboratory Findings
; anemia often with IDA
; often elevated ESR, maybe normal
;
*thrombocytosis(>600,000/mm3)
more commonly
; normal or mild leukocytosis
; low albumin
; elevated stool ¥á1-antitrypsin
# Plain Abdomen
; normal
; partial SI obstruction
; thumb printing of the colon wall
# UGI
; small bowel involvment °¡ ÀÖÀ¸¸é, ¸ÕÀú ¼±ÇàµÇ¾î¾ß ÇÑ´Ù.
; aphthus ulcer, thickened nodular folds, narrowing of lumen
; linear ulcer --> cobblestone appearance
; terminal ileum
-
*¡ãcommon involved area
; eccenteric regions
- skip areas
; fistula between bowel, sinus tracts, strictures
# Barium Enema
; smilar mucosal change of colon
; cecum, ascending colon
-
*¡ãcommon involved area
# Ultrasonography & CT
; intraabd. abscess
# MRI in pregnancy
# Colonoscopy with biopsy
; more helpful
; patchy, nonspecific inflammatory changes(erythema, friability, loss of vascular pattern), aphthus ulcer, linear ulcer, nodularity, strictures
-
*ˤ˂
¼Ò°ßÀ¸·Î Crohn diseaseÀ»
ÀǽÉÇÒ ¼ö
¾øÁö¸¸, deeper layer¿¡
º´º¯ÀÌ ÀÖ´Â
°æ¿ì¿¡´Â ÀǽÉÇØ¾ßÇÑ´Ù.
;
*noncaseating granuloma
-
*¡ãcharacteristic histologic finding
;
*transmural inflammation
-
*¡ãcharacteristic histologic finding
Treatment
# *small
bowel involvment¸¸ ÀÖ´Â
°æ¿ì
;
*prednisone 1-2mg/kg/day(max.
40mg)°¡ first treatment
# Steroid Cream In Perianal Ds
; sitz baths°°ÀÌ ÇØ¾ß ÇÑ´Ù.
# Aminosalicylate
; sometimes more effective
; delayed release 5-Aminosalicylate(Asacol) 50mg/Kg/day (max. 3g/day)
# azathioprine 1-2mg/kg/day (or its metabolite 6-MP)
; poor response to steroids or steroid dependent¿¡ ¶§¶§·Î È¿°úÀû
# metronidazole
; effective in intractable Crohn disease
# Azathioprine + Metronidazole
; helpful in prianal fistulas
# cyclosporine, ciprocloxacin
# restricting diet ´Â ÇÇÇØ¾ß ÇÑ´Ù.
# Acute with severe pain, anorexia, fever, abdominal tenderness, elevated white cell count°¡ ÀÖ´Â °æ¿ì
; microperforationÀ» Æ÷ÇÔÇÏ´Â infectious processÀ» rule outÇÏ±â ¾î·Æ±â ¶§¹®¿¡ intravenous steroid + AB(for gram-negative & anaerobes)À» ÁØ´Ù.
; ultrasonography or abdominal CT¸¦ ½ÃÇàÇÑ´Ù.
# Nutional therapy
;
*effective primary therapy
; High calorie oral supplement°¡ ¼º°øÀûÀÌÁö ¸øÇÑ ÀÌÀ¯
- early satiety or exacerbation of symptom(abdominal pin, vomiting, diarrhea)
; TPN
- effective in nutrional repletion & in quieting active disease
;
¢¾Continuous Adminstration Of Nocturnal Nasogastric Feeding
- complex enteral feedings
/ 500-1000kcal nightly
/ 50-80kcal/kg/night monthly every 4months
- elemental diet
/
*superior in inducing remission
/ continuous as 24hr or overnight
/
¢¾Advantages
1) free of side effects
2) avoids problems ass. with corticosteroid therapy
3) simultaneouly addresses nutritional rehabilitation
/ disadvantages
1) early relapse on discontiuing treatment
2) no response to perianal & colon disease
/
¢¾Indication
: severe nutritional depletion
: severe growth failure
: unreponsive to conventional treatment
/
*remission¿Â
ÈÄ¿¡´Â delayed-release
5-minosalicylate ȤÀº alternate-day steroid·Î
À¯Áö¿ä¹ýÀ» ÇÑ´Ù.
# Surgery
;
¢¾½ÅÁßÇØ¾ßµÈ´Ù. ±×ÀÌÀ¯´Â
- recurrance rate after bowel resection is high(>50% by 5yr)
- increase risk of requiring additional surgery
- potential complication
/ fistula, stricture, anastomotic leak, postoperative partial small-bowel obstruction secondary to adhesions, short-bowel syndrome
; Indication
- localizing disease of small bowel or colon unresponsive to medical Tx.
- bowel perforation
- stricture with symptomatic partial bowel obstruction
- intractable bleeding
;
*removing bowel up to margins that
are free of disease
- better outcome than most involved areas
; symptomatic small-bowel stricture
-
*stricturoplasty rather than
resection
; severe perianal disease
-
*colectomy with conventional
ileostomy
/ continent ileostomy ȤÀº endorectal pull-through´Â ±ÇÀåµÇÁö ¾Ê´Â´Ù.
Prognosis
; *high
morbidity & low mortality active full life
- Ä¡·á¿¡µµ ºÒ±¸ÇÏ°í ¼³¸íµÇÁö ¾Ê´Â Àç¹ßÀÌ ÀϾÙ.
; up to 15%
- permanent decrease in linear growth
; *½Ã°£ÀÌ
°¥¼ö·Ï involved region of
intestine ÀÌ Ä¿Áö°í, complicationÀÌ ÈçÇÏ´Ù.
; *°á±¹¿¡´Â
°ÅÀÇ ´ëºÎºÐÀÇ
ȯÀÚ°¡ ¼ö¼úÀ»
¿äÇϰí, Àç¼ö¼úÀÇ
ºóµµµµ ³ô´Ù.
-
*symptom onset¿¡¼
¼ö¼úÀÇ ½Ã±â±îÁöÀÇ
±â°£ÀÌ ¼Ò¾Æ¿¡¼
´õ ª´Ù.
283.3 Behcet Syndrome
multisystem vasculitis, very rare in children
Clinical Manifestation
1. aphthous stomatitis : 2-10 mm in diameter, mouth, post. pharynth
covered by white yellow membrane, painful
2. erythema nodosum
3. arthritis
4. ±×¿Ü genital ulcer, CNS involvement, myositis, iridocyclitis
segmental lesion in colon or distal small bowel
Treatment
1. corticosteroid
2. immunosuppressive : chlorambucil, cholichine
3. resection : intestinal obstruction½Ã
Chapter 284. Dietary Protein Intolerance (Food Allergy)
immunologically mediated response to dietary antigen
several immunologic mechanism
i) immediate anaphylactic hypersensitivity involving IgE Ab
ii) Ab dependent cytotoxic hypersensitivity involving Ig M or Ig G
iii) immune complex hypersensitivity
iv) cell mediated hypersensitivity
Clinical Manifestation
GI ¾îµð¶óµµ ħ¹ü °¡´É
1. mouth : recurrent shallow, mucosal ulceration & perioral dermatitis
2. stomach : i) intragastric antigen -> hm, edemaous inflammation
ii) acute vomiting & watery, bloody diarrhea
iii) fatal anaphylactic shock (rare)
3. small intestine
i) acute watery diarrhea
; immediate response to antigen ingestion
; w/wo vomiting and abd. cramps
ii) chronic diarrhea & failure to thrive
; after ingestion of milk, soy, egg, fish
; anorexia, chronic diarrhea, retarded growth
iii) excessive enteric protein & blood loss
; hypoproteinemia, iron deficiency without obvious GI Sx.
in older infant¿¡¼ breast milkÀÇ weaning
milk formula feedingÀÌ withdrawl½Ã
eosinophilia(+), cow's milk withdrawal ½Ã Sx. improve
4. colon
pancolitis causing profuse bloody diarrhea in young infant
diarrhea stool : abundant eosinophils (+)
eosinophil gastroenteritis¿Í °¨º°µÇ¾î¾ßÇÔ
Diagnosis
1. clinical Dx.
#86 withdrawal of milkÈÄ acute Sx.Àº 48½Ã°£À̳» ¼Ò½Ç, chronic Sx.Àº 1ÁÖÀ̳»
rechallenging½Ã with caution
#81 2. dietary Ag¿¡ ´ëÇÑ GI responseº¸±â À§ÇÑ
¨ç skin tests,
¨è circulating Ab titers
¨é complement assay
¨ê copro Ab titer -> of not proven Dx. value
3. 50% of cow's milk intolerance pt.¿¡¼ soy protein¿¡µµ intolerant
DDx. ; enteric infection, lactose intolerance, other N-S infl. bowel ds
Treatment
1. prolonged breast feedingÇϸé ÈÄ¿¡ cow's milk intolerance °¨¼Ò
2. offending food removal (48, 72½Ã°£³» Áõ»ó È£Àü)
i) non-milk containing formula in young infant
(soy feeding, hydrolyzed milk protein feed)
ii) enteric protein & blood loss
-> fresh milk¸¦ processed (evaporated or powdered) milk·Î
3. oral sodium cromoglycate : ¸¹Àº À½½Ä¿¡ ´ëÇÑ intoleranceÀÖÀ» ¶§
intestinal Sx. suppress
Prognosis
variable À̳ª ´ë°³ transitory
50% ´Â 1³â³», ´ë°³ 2³â³» ¼Ò½Ç
Chapter 285. Eosinophilic Gastroenteritis
ÁÖ·Î stomach, upper SI¿¡ infl. of eosinophil
¶§·Î esoph. distal SIµµ ħ¹ü
Sx. : abd. pain, V. D. delayed growth & Wt. gain
¶§·Î atopic Sx. - rhinitis, asthma, peripheral eosinophils
excessive protein loss (alb. Ig)
bowel thickening & granuloma : rare
´ë°³ chr. debilitating course, corticosteroid Tx.
CHAPTER 286. Malabsorptive Disorders
Table 286-1 Generalized Malabsorptive States in Children
# Characteristics of malabsorption syndrome
; abd. distension
; pale, foul smelling, bluky stools
; wasting of muscles, esp, prox. m. group
; poor weight gain or weight loss
; growth retardation
# Disaccharidase deficiency
;
*¡ãcommon congenital disorder affecting digestive enzyme
Table
286-2. Specific Defects of Digestive-absorptive Function in Children
286.1 Evaluation Of Children with Suspected Intestinal Malabsorption
Clinical Manifestation
malabsorption°ú ´Ù¸¥ Ds.¸¦ DDx.ÇÏ´Â ÁÖµÈ ¹æ¹ý
1) Hx.
i) family Hx.
ii) time of onset
iii) relation to dietary content & intake
iv) description of stool
v) body Wt. & length
2) signs of malnutrition
i) muscle wasting
ii) edema
iii) mouth sores
iv) smooth tongues
v) excessive bruising
3) rectal exam. Áß¿ä : initial step
i) anus & rectum assess
ii) stool exam. for gross microscopic, chemical study
a. panc. insufficiency ½Ã excessive droplet of fat & undigested meat fiber
b. intestine ds.½Ã crystalline aggregates of monoglycerides & fatt acid
Laboratory Manifestations
Fat
# Microscopic Examination Of Stool For Fat
;
*¡ãuseful screening test
; Sudan red stain
;
*more than six to eight droplets
per LPF - abnormal
1) absorptive function
## 86 1. fat
i) fecal fat balance study
20g/day ÀÌ»ó ¼·ÃëÈÄ ÃÖ¼Ò 4Àϰ£ collection
15% ¡è excretion in NB -+
10% ¡è excretion in older CH -+ ½Ã abn.
ii) serum carotene conc.
< 50 ug/dl : malabs.
> 100 ug/dl : normal
iii) direct stool microscopy for fat content
Carbohydrate
# Benedicts test
;
*clinitest reagents(reducing
substance)À» ÀÌ¿ëÇÏ¿© carbohydrate in stoolÀ» °Ë»ç
; stool sugar ¾ç > 0.5%½Ã abn.
;
*sucroseÁ¦¿ÜÇϰí dietary sugar´Â
reducing sugarÀ̹ǷΠ¾ç¼º
¹ÝÀÀÀ» º¸ÀÓ.
; sucrose °Ë»ç½Ã´Â stoolÀ» HCl·Î heating½ÃÄÑ °¡¼öºÐÇØ
# Fresh Stool pH
;
*< 5.6À̸é abnormal
; unabsorbed sugar°¡ bacteria¿¡ ÀÇÇØ oraganic acid»ý¼º Áõ°¡
# ¡ÚStool
Electolyte Contents
;
*2x[sodium]+[potassium]+50
;
*< 290mOsm/LÀ̸é osmotic diarrhea, carbohydrate malabsorption
# Breath Hydrogen Test
: indirect
hydrogen conc. in expired air´Â sugar p.o. 2g/Kg (max 50g)
-> USI¿¡ ¼ Èí¼ö ¾ÈµÇ¸é distal intestine¿¡¼ bacteria¿¡ ÀÇÇØ
hydrogen gasÇü¼º -> absorb -> expiration
ù 2½Ã°£³» breath hydrogenÀÌ 20ppmÀÌ»ó½Ã
Protein
Table 286-3
Gasrointestinal Causes of Hypoproteinemia
endogenous fecal protein source ¶§¹®¿¡ balanced study´Â ºÎÁ¤È®
i) fecal nitrogen : rough, quick
ii) enteric protein loss : choice
51CrCl iv 4ÀÏÈÄ stool collectionÇÏ¿© 0.8%ÀÌ»ó loss½Ã abn.
iii) fecal clearance of serum ¥á1-antitrypsin : simple
48hr collectionÇÏ¿© 15ml/day ÀÌ»ó clearance ½Ã abn.
Other Nutrient
iron, folic acid in RBC, s-Ca, Mg, Vt. D, & metabolite Vit. A, Vt. B12
localization of size of malabsorption
i) iron, D-xylose : upper SI
bl. level < 25mg/dl - 1hr after oral xylose ½Ã small intestine lesion
14.5g/m2½Ã prox. intestinal mucosal lesion
ii) Vt. B12, bile salt : distal bowel
-> Schilling test : radioactive B12 oral
-> 24hr ÈÄ urine excretion ÃøÁ¤
urinary excretionÀÌ <5%½Ã abn.
Diagnostic Procedures
Microbiologic
: giardiasis 10 inf. cause
Small Bowel Biopsy
i) celiac ds.
ii) abetalipoproteinemia, acrodermatitis enteropathica
eosinophilic gastroenteritis, congenital villus atrophy
iii) giardiasis, lymphangiectasia, gamma globulin deficiency
viral enteritis, tropical sprue, cow's milk or soy intolerance
Hematologic
i) iron deficit
ii) megaloblastic ... folate, Vt. B12 deficit
iii) acanthocytosis ... abetalipoproteinemia
iv) lymphocyte defect or neutropenia, ass. with Shwachman-diamond synd.
Imaging Procedures
i) plain abd. & barium enema : intestine stasis ÀÇ siz. ¿øÀÎ
ii) 99mTc scan : duplication, Meckel's diverticulum
iii) US, panc. mass, biliary tree abn.
iv) ERCP
disaccharidase assay
286.2. Chronic Malnutrition
exocrine pancreatic insuff.
* malnutritionÀÇ °¡Àå ÈçÇÑ ¿øÀÎ( Kwashiorkor, marasmus )
intestineÀº protein caloric malnut.¿¡ resistant
286.3. Liver & Biliary Disorders
bile salt °¨¼Ò½Ã +- steatorrhea
+- bone lesion due to Vt. D malabsorption
+--Vt. E abs. ¡é -> chronic neuropathy
286.4. Intestinal Infections
# Giardiasis
;
*¡ãcommon infectious causes
; diarrhea, vomiting, bloating, gas
;
*day care children(toddlers) -
special risk
# coccidiosis due to Isospora belli, I. hominis
# intestinal hookworm
286.5. Immunodeficiency
: defective resistance to enteric microflora
(1) Congenital deficiency
1) congenital sex-linked panhypogammaglobulinemia ( Bruton )
mild intermittent diarrhea ... 2¼¼³» ´ë°³ È£Àü
giardia ¡è
2) Ig A deficiency
TMC congenital immunodeficiency
IBD, nodular lymphoid hyperplasia, celiac ds. : common
giardia ¡è
3) combined immunodeficiency : disaccharide activity ¡é
severe diarrhea & malabsorption -> high mortality in this group
4) neutropenia & neurophil dysfunction
neutropenia pt.¿¡¼ NEC´Â cause of fever, RLQ pain
chronic granulomatous ds. ȯÀÚ¿¡¼ granuloma´Â intestine¿¡ ÆÄ±ÞµÇ¾î
diarrhea, malabsorptionÀ¯¹ß
(2) Acquired immunodeficiency
¨ç oral eso. -> Candida / HSV / CMV / EBV
¨è enteric
i) AIDS ; C. albicans / CMV / blastocytosis / C. difficle / Cryptosporidium
ii) BM transp ; C. diff / adeno V / Rota V
286.6 Stagnant Loop Synd.
( Blind loop synd. Bacterial overgrowth synd.)
Eti.
1. incomplete bowel obstruction
a. congenital i) malrotation with duodenal band
ii) stenosis
iii) diverticulum
b. acquired i) postop. intestinal adhesions
ii) longstanding Crohn's ds.
2. neuromuscular dysf. -> motility disorder
i) intestinal pseudo-obstruction
ii) hollow viscus myopathy
Pathogenesis
i) enteric bacteria°¡ peristalsis¿¡ ÀÇÇØ incompletely clearedµÇ¾î upper SI ¿¡ colonize
-> bile salt deconjugationÇÏ¿© dietary fatÀÇ
ineffective intraluminal processing & steatorrhea
ii) Vt. B12¿Í °áÇÕ : Èí¼ö ¹æÇØ
iii) microvillus brush border memb. damage
iv) disaccharide activity °¨¼Ò
C/M
i) chronic incomplete bowel obst. Sx. : distension, pain, vominting
ii) steatorrhea ... pale foul bulky stool
megaloblastic anemia (Vt. B12 def.)
diarrhea from disaccharide deficiency
Tx.
i) oral bactrim : temporary improvement
ii) definite Tx. : operative correction
286.7 Short Bowel Synd.
small intestine (w/wo loss of some large intestine )ÀÇ
congenital or postnatal lossÈÄÀÇ malabsorption & malnutrition disorder
(1) Congenital
ass. with malrotation atresia, gastroschisis
(2) Massive intestinal resection
NB :small bowel 2-3mÀÇ 25% ÀÌ»óÀÇ resection½Ã
fluid-nutritional problem ÃÊ·¡ °¡´É
* resectionÈÄ infantÀÇ ¼ÒÈ, Èí¼ö ±â´ÉÀº 2³â Áö³ª³Ä ÀÚ¿¬ °³¼±
ileum : sole site of absorption for bile salts -> fat Èí¼ö
resection½Ã ileocecal sphincterº¸Á¸ ÀÌÀ¯
i) colonic floraÀÇ retrograde flow¸¦ impede
ii) ³²Àº small bowel mucosa¿¡ nutrient contact¸¦ prolongation
Cx. after massive resection
i) gastric acidity & retrograde bacterial contamination of intestinal lumen
: absorption decrease
ii) bile salt loss : fat & fat soluble Vt. malabsorption
colon¿¡¼ bile salt°¡ water & Enzyme secretion increase
iii) hyperoxaluria after distal SI resection
-> but nephrolithiasis : rare in early CH
iv) CMI : normal but Ig ¡é
v) mid & distal jejunum & ileum resection ½Ã fluid balance À¯ÁöÇÒ ÇÊ¿ä¾øÀ½
Tx.
1. TPN
2. liquids or liquid formulas : isotonic initially & frequent small feeding
excessive water ±ÝÁö
steatorrhea½Ã MCT
constant intragastric infusionÀÌ bolus feedingº¸´Ù net fluidretention À» Áõ°¡
glucose than disaccharide (<5g/dlÀ¯Áö - fluid isotonicity¶§¹®)
Vit. supplementation : A, D, E, K
vit. K -> PT monitorÇÏ¿© supplement
s-Ca, Mg, K, phosphorus monitor & supplem.
large ileal resection ½Ã Vt. B12 100ug inj. monthly for life
antidiarrheal agents : rarely helpful
cholestyramine : colonµµ´ÞÀü bile acid ¿Í °áÇÕÇÏ¿© fecal Na, water loss °¨¼Ò
but massive resection À̳ª severe steatorrhea½Ã aggrevation
antacid : not - proven
oral antibiotics for stagnant loop synd.
intellectual function : preserved
286.8 Gluten-Sensitive Enteropathy (=Celiac Disease)
permanent intestinal notolerance to gliadin, ¹Ð¿¡ ÇÔÀ¯µÈ ´Ü¹éÁú
causes severe small intestinal mucosal lesions in susceptible individuals
Pathogenesis
¨ç genetic and environment factor °ü¿©
ass. with class HLA B8 and class II HLA antigen DR3, DQ, W2, DR4
80-90% HLA B8 (+)
¨è Breast feeding½Ã risk decrease
¨é enteric infection (human adeno v. 12)½Ã riskÁõ°¡
mechanism of gliadin damages to small intestine : unknown
-> celluar & cell mediated immune responseÀÚ±Ø
Clinical Manifestation
Table 286-4 Active Childhood Celiac Disease -42 Cases
wide range
typical : irritability, anorexia, chr. diarrhea in later in 1st year
constant features : decreased rates of Wt. gain & linear growth
Evaluation
; anemia & hypoproteinemia
;
¡ÚSerologic Test
-
*antigliadin antibodies
/ not reliable enough
-
*serum IgA-endomysial antibodies
/ confirm diagnosis
/ exception) IgA-deficient patients
: common, iron, folate, vit B12 deficiency
ii) hypoalbuminemia & circulating ¥ã-globulin
iii) steatorrhea : 4 day balanced study»ó fat excretion > 10%
iv) fasting s-carotene level ¡é (< 50ug/dl)
low serum 25-OH-vit D, calcium, vit. A level
v) PT ¡è
vi) diffuse small bowel mucosal damage
-> flat oral GTT, blood xylose conc. < 25mg/dl
vii) barium contrast ; diffusely dilated SI, coarse mucosal folds
viii) bone X-ray : osteoporosis, rickets (rare)
selective Ig A deficiency & IDDM ¡è
adult¿Í ´Þ¸® child atophy´Â Áõ°¡ ¾ÈÇÔ
ix) Ab to gliadin+- Ig G -> sensitive
+- Ig A -> specific
#81 USI mucosa¿¡ diffuse lesion -> peroral suction biopsy
LM »ó
i) short, flat villi
ii) deepend crypts
iii) irregular vaculated surface epi. with lymphocytes in epith, layer
Rota virus, giardia, tropical sprue°°Àº inf. ½Ã
villous flattening & elongate cryptÃÊ·¡ °¡´ÉÇϳª enterocyteÀÇ marked abn.(-)
i) mucosal suction biopsy : duodenal & jejunal mucosal lesion
ii) clinical & lab. response to a gluten free diet
iii) reappearance of lesion after gluten challenge
-> ÃÖ¼Ò Ä¡·áÈÄ 2³âÈÄ ½ÃÇà, ¡ñ mucosal healingÈÄ
Pathology
i) tropical sprue
ii) protein intolerance
iii) immune deficiency
iv) eosinophilic gastroenteritis
Treatment
i) gluten free diet ( wheat, rye, barley )
ii) ±Þ¼º±â¿¡´Â fat-soluble vit, iron, folateº¸Ãæ
iii) lactase deficiency ½Ã disaccharide restriction
Prognosis
i) gluten free diet·Î mood & appetiteÁõ°¡ÈÄ diarrhea °¨¼Ò ´ë°³ Ä¡·á 1ÁÖÈĺÎÅÍ È£Àü
ii) preadolescence¿Í adolescenceµ¿¾È¿¡´Â celiac ds. childrenÀÌ »ó´ç·®ÀÇdietary glutenÀÇ Áõ»ó ¾øÀÌ tolerable
iii) adult pt.¿¡¼ intestinal malignancyºóµµ ´õ ³ô´Ù.
286.9 Immunoproliferative Small Intestinal Ds.
Pathology : thickened mucosal folds, duo. or jejunal nodularity
lymphoplasmacytic infiltrates
C/M initial : intermittent diarrhea. abd. pain
later : persistent chronic diarrhea, malabsorption
Wt. loss, digital clubbing, growth failure
Dx. : endoscopic biopsy of multiple duodenal & jejunal mucosal sizes
serum marker of Ig A
Tx.
1. early lesion : 6 Mo ÀÌ»óÀÇ TC therapy
2. prelymphomatous stage : cyclophosphamide w/wo prednisone
3. lymphoma : combination of cyclophosphamide & TC
doxorubicin, teniposide, prednisone
Px. : early Tx. of AB - excellent
later Tx. - poor
286.10 Other Malabsorptive Syndrome
1. Intestinal lymphangiectasia
dilatation of lymphatic vessels
leakage of lymph into intestinal lumen
steatorrhea, protein losing enteropathy, fat malabsorption, chylous ascites
hypoalbuminemia, hypogammaglobulinemia, edema, lymphocytopenia
causes :
surgical damage to lymphatic vessels, chr. RHF, constrictive pericarditis
retroperitoneal tumor, malrotation with lymphatic obstruction
Turner SD, Noonan SD
Dx. elevated fecal ?1-antitrypsin
Rad. uniform symetric thickening of SI
2. Microvillus Inclusion Disease ( Congnital Microvilus Atrophy)
intractable watery diarrhea and severe malabsorption at birth
inherited in AR pattern
Dx. villus atrophy, crypt hypoplasia, microvillus inclution in enterocyte
Tx. somatistatin analog octreotide
TPN bowel transplantation
3. Autoimmune Enteropathy
chr. diarrhea and malabsorption after 6 Mo
±×¿Ü arthritis, membraneous GN, thrombocytopenia, hemolytic anemia
Dx. villus atrophy, crypt hyperplasia, chr. inflammatory cellin
lamina propria antienterocyte Ab (IF)
Tx. Prs, Azathioprine, cyclophosphamide, cyclosporine
4. Tufting Enteropathy
persistent watery diarrhea in 1st weeks of life
Dx. SI biopsy focal epithelial tufts(80-90%) : shortening of microvilli
5. Tropical Sprue
fever, malaiseÈÄ watery diarreha
¼öÀÏÈÄ chr. malabsorption, internittent diarrhea, anorexia,
malnutrition sign : night blindness, glossitis, stomatitis, cheilosis
hyperpigmentation, edema, megaloblastic anemia,
Tx.
antidiarrheal agent
nutrient : folate
broad spectrum antibiotics : sulfonamide, TC (for 3-4wks)
6. Wolman Disease
lethal lipoidosis : lipid accumulation
vomiting, hepatosplenopathy, steatorrhea
286.11 Enzyme Deficiency
Enterokinase Deficiency
complete absence of pancreatic preteolytic activity
( enterokinase°¡ pancreatic trypsinogenÀÇ essential activator )
severe diarrhea, failure to thrive, hypoproteinemia
duodenal juice»ó +- trypsin activity (-)
+- lipase, amylase : normal
Disaccharidase Deficiencies
SIÀÇ brush border memb. surf.¿¡ Á¸Àç
´ë°³ secondary
disaccharide intolerance½Ã responseÀ¯»ç
incomplete disacch. hydrolysis at brush border
-> sugar ¡èin distal lumen & organic acid, H+
-> i) sugar & organic acid°¡ water¸¦ ²ø¾î µéÀÓ
; watery diarrhea & frothy stool, low pH, excessive sugar in stool
ii) excoriate the buttock
bloating, borborygmi (+), steatorrhea rare
infancyÀÌÈÄ abd. pain
Dx. i) clinitest (+) : if reducing sugar (lactose)
ii) mucosal biopsy for disaccharidase activity
iii) hydrogen breath test after oral sugar load
iv)stool PH < 6
Lactase Deficiency
; congenital absence : rare
-
*usual mechanism : developmental
pattern of lactase activity
/ Á¤»óÀûÀ¸·Î lactase activity´Â late in fetal life¿¡ Áõ°¡ÇÏ¿© 3yrÀÌÈÄ¿¡ °¨¼ÒÇÑ´Ù
; AR
; *lilely
depletion secondary to diffuse mucosal disease
; Symptoms
- onset in response to ingestion of lactose, sugar in milk
-
*explosive watery diarrhea
/ ass. with abdominal distension, borborygmi, flatulence, excoriated diaper area
- recurrent, vague, crampy abd. pain
- episodic midabdominal pain in school- and proschool-aged child
; Treatment
- milk elimination & lactase preperation
Sucrase-Isomaltase Deficiency
; AR
; Symptoms
- bloating, watery diarrhea, excoriation of buttock
-
*no recurrent abdominal pain
; *clinitest»ó (-) - suctose´Â
reducing sugar ¾Æ´Ô
; breath test»ó ¡èH2 after sucrose ingestion
; small intestinal mucosa - normal
286.12 Defects Of Absorption Of Transport
Glucose-Galactose Malabsorption
Eti. i) congenital : AR, renal tubular epithel.µµ mild effect
ii) acute viral enteritis : severe chronic diffuse mucosal damage
C/M : watery stool after glucose, breast milk, conventional formula
Tx : fructose´Â tolerate : restriction of glucose & galactose
Abetalipoproteinemia
; AR
; Clinical Manifestation
-
*severe fat malabsorption from
birth
- failure to thrive during 1st yr
- pale, foul smelling, bulky stool
- distended abdomen
- absent DTR due to peripheral neuropathy
; Diagnosis
- *acanthocytes in PBS & very low levels of
S-cholesterol(<50mg)
- TG accumulation in villus of duodenal mucosa
; Treatment
- large amount fat sol. vit. A, D, E, K
- massive vit E. (100mg/Kg/24hr½Ã) neurologic degeneration
- MCT
Homozygous Hypobetalipoproteinemia
Chylomicron Retention Ds.
Amino Acid Transport Defects
1) cystinuria ; no GI Sx
2)
¡ÚHarnup ds
; malabsorption of tryptophan
--> *ataxia, intellectual deterioration, pellagra like rash,
diarrhea
3) methionine malabsorption
; diarrhea, sweet urine with ¡è¥á-hydroxybutyric acid
4) blue diaper synd. ; defective absorp. of tryptophan
Vitamin B12 malabsorption
1. juvenile pernicious anemia : intrinsic factor Çü¼º (-)
2. transcobalamine II defect : vit B12ÀÇ intestinal transport proteinÀå¾Ö
3. Imerslund : defective ileal absorp. of vit B12
Congenital Malabsorption Of Folic Acid
megaloblastic anemia, cerebral degeneration
Chloric Losing Diarrhea
cong. defective ileal chloride transport ass. maternal polyhydramnios
severe watery diarrhea since birth
-> hypo K, hypochloremia, alkalosis
Congenital Sodium Diarrhea
diarrhea since birth
maternal polyhydramnios
acidosis
Vitamin D Dependent Rickets
AR, malabs. of Ca
Primary Hypomagnesemia
Acrodermatitis Enteropathica
; Etiology
-
*zinc deficiency secondary to zinc
malabsorption
;
¡ÚClinical Manifestation
- rash around mucocutaneous junction & extremity
- alopecia
- chronic diarrhea ¶§·Î steatorrhea
- unTx.½Ã failure to thrive
; intestinal mucosal biopsy
-
*Paneth cell
; Treatment
-
*oral zinc sulfate 1-2mg element
zinc/kg/24hr
- after treatment rapid healing skin lesion, diarrhea
Menkes (Kinky Hair) syndrome
; AR
; Characteristics
- growth retardation, abn. hair, cerebellar degeneration, early death
; Pathogenesis
- unknown
-
*cellular copper transport defect
; s-Cu & ceruloplasmin ¡é, cellular Cu ¡è
Bile Acid Malabsorption
Drug Induced Absorptive Defects
1. MTx : arrest of enterocyte mitosis -> mucosal lesion
2. neomycin (large amount) : affect mucosal structure
3. sulfasalazine : folic acid abs. ¡é
4. cholystyramine : hypoCa, steatorrheaÃÊ·¡ <- bind to Ca & bile acid
5. phenytoin : Ca abs. ¡é -> rickets
Chapter 287. Chronic Diarrhea
# definition of diarrhea
; excessive loss of stool water & electrolyte
; stool volume 15mg/kg/day in infant, 200g/day at 3 years
# Chronic diarrhea
; consistent increase in stool frequency
; decrease in stool consistency or increase in stool volume
Characteristics Of Diarrhea
Osmotic diarrhea : feedingÀ̳ª medicationÀ» Áߴܽà Diarrhea ¸ØÃ߸é common
Secretory diarrhea : fasting½Ã¿¡µµ diarrhea Áö¼Ó, rare and primarily in infancy
stool frequency > 5/day, watery & large volume (more than 75%)
through day and night,persistence a diarrhea beyond 24-48hr
require hospitalization, complete bed rest, IV hydration
# Diarrheal stool
; osmolality 280-330mOsm/L
; osmotic gap = 290-2(Na++K+)
; ¡Úosmotic diarrhea
-
*low Na+ (<50mEq/L)
osmotic gap (>160mEq/L)
; secretary diarrhea
- high Na+ (>90mEq/L) osmotic gap(<20mEq/L)
287.1 Osmotic Diarrhea
Table 287-1
Differential Diagnosis of Chronic Osmotic Diarrhea on the Basis of Pathophysiology
Table 287-2
Differential Diagnosis of Chronic Osmotic Diarrhea on the Basis of Age of
onset
Table 287-3 Patterns of Presentation of Chronic Osmotic Diarrhea
287.2 Secratory Diarrhea
Table 287-4
Differential Diagnosis of Chronic Secretory Diarrhea on the Basis of Pathophysiology
Diagnosis
1. congenital transprot defects
: begin at birth or in the 1st few days with anorexia, vomiting
formula change½Ã transient improvement
2. protracted diarrhea (intractable diarrhea of infancy )
1) infection : Ab to HIV
2) anatomic or functional intestinal obstruction : UGI
3) secretory tumor : S-VIP level, U-VMA, US, CT, MRI
4) immune def.
5) disorder of epi. turnover or differentiation : lab.
3. biopsy : early in evaluatin duodenal fluid culture & EM
Factitious Diarrhea
1. phenolphthalein(Ex-Lax)
turn pink on alkalinization-turn colorless with acidification
2. laxatives
measuring stool electrolyte, Mg, S,
chromatographic analysis of anthracene derivatives
3. low stool osmolality (less than 280mOsm/L) : add water to stool
287.3 General Therapeutic Consideration
Tx. for specific cause
adequate nutrition balance with bowel rest
protein-calorie balance
fluid-electrolyte balance
diet restriction : postenteritis lactose intolerance in infancy
: 4-6ÁÖ µ¿¾È lactose free milk formula or soy based formulaÁØ´Ù.
control of chronic non-specific diarrhea
regular diet ingestion & nonprotein fluid 90ml/kg/day
oral loperimide 0.1-0.2mg/kg/day #2-3
Broad spectrum antibiotics : metronidazole, TC, CM, AP, EM with NM for 2wk
Treatment Of Secretory Diarrhrea
; IV nutrition and complete bowel rest
; Refeeding
-
*BW°¡ 50%ile ÀÌ µÈ
ÈÄ¿¡ refeeding
- benefit on mucosal growth of enteral nutrients
;
¡ÚDrug Therapy
- opiates or opiate derivatives
/ decrease fluid transient throuth guts
- loperamide
/ high antidiarrheal specificity
- cholestyramine
/ anion exchange resin for bile acids
/ protect against direct bile-induced injury, bile acid-induced secretion in colon
- *somatostatin
/*reduce secretory diarrhea caused by neuroendocrine tumors and
villous atrophy
-
*PG synthesis inhibitor
/ indomethacin, bismuth subsalycylate, 5-aminosalycylate
/ decrease diarrhea in inflammatory diarrhea
- immunosuppressive agents
/ autoimmune enteropathy
Chapter 288. Recurrent Abdominal Pain Of Childhood
; Incidence : 10% of preschool and school-aged children
2¼¼ÀÌÇÏ´Â organic cause°¡ ¸¹À¸¸ç, older children¿¡¼´Â 10%¿¡¼ organic causeÀÌ´Ù.
`functional abdominal pain' : recurrent abdominal pain without organic cause
Etiology
¨çnot ass. with specific structural or biochemical causes
¨èchr. peripheral pain
¨épsychosocial stress
¨êpersonality pattern
¨ëreinforcement of illness behavior
Clinical Manifestation
non-specific
variants
1. irritable bowel syndrome
2. nonulcer dyspepsia
nocturnal painÀº organic causeÀÌÁö¸¸ functional painÀϼöµµ
periumbilical pain
distracted from pain
good periods with remission of Sx.
recurrence without apparant cause or stressful period
Diagnosis
normal P/E & Hx. of good growth with rectal exam.
pale appearance
initial nondirect interview technique
family medical Hx.
Lab. : CBC, ESR, U/A, stool exam. for parasite
plain X-ray, US, UGI, esophagogastroduodenoscopy
Differential Diagnosis
¨ç organic cause
¨èchronic constipation
¨é parasite infection
¨êlactase deficiency
¨ë GU disorder : hydronephrosis
¨ì Crohn disease
¨írecurrent pancreatitis
¨î peptic ulcer, H. pylori infection
¨ï abdominal migraine or epilepsy
Treatment
reassurance of the children and family member
medication usually unheplful
biofeedback & relaxation technique
lactose free diet
Chapter 289. Acute Appendicitis
; *¡ãcommon cause of abd. surgery in child
2¼¼ ÀÌ»óÀÇ ¾î¸°ÀÌ¿¡¼ emergency op. Ix.
i) acute appendicitis
ii) trauma to viscera
iii) intussusception
iv) adhesive bowel obstruction
v) lesion of ovary
risk of perforation i) 1-4yr : 74%
ii) 5-8yr : 66%
iii) adolescents: 30-40%
Epidermiology
2¼¼ÀÌÇÏ unusual, 1¼¼ÀÌÇÏ rare
peak age : teenage, young adult years M>F
season : °¡À», º½
Etiology
1. luminal obstruction :TMC
i) hard concretions (appendicial fecalith)
crushable fecal impaction in appendix
appendicial calculi (hard, calcified fecaliths) : radioopaque 15-20%
ii) narrow appendicial mesentary : distal torsion- acute ischemic necrosis
iii) hyperplasia of submucosal lymphoid tissue by inf.
iv) viral or bacterial (Yersinia, salmonella, shigella)
v) cystic fibrosis or carcinoid tm.
2. nonobstructive lesion : rare
Pathology
1. young CH : rapid course
3 phases
I) acute obstruction of appendix
-> mucus secretion -> mucosal vessels compression
-> ischemia, necrosis, ulceration
ii) bacterial invasion & inf. of appendicial wall
infl. cell infiltration in all layer
iii) app. wall necrosis perforation at tip of appendix.
distal to obstruction fecaliths
2. older CH
´ë°³ omentum°ú adj. ileumÀÌ inflammatory appendix¿¡ adhere prior to perfo.
-> wide spread fecal spillage¸¦ ¿¹¹æ
-> localization abscess in Rt. iliac fossa
### infant, young children½Ã appendicitis°¡ quickly perf.
& generalized peritonitis È£¹ß ÀÌÀ¯
; omentumÀÌ smallÇϰí ineffective in localizing the infection
3. bacterial invasion of the mesenteric v. - portal v. sepsis
- liver abscess formation
Clinical Manifestation
# classic triad
; pain, vomiting, fever
; pain
- initial stage : periumbilical
; emesis
- follows onset of pain
;
*symptoms sequence°¡
Áß¿äÇÏ´Ù
-
*pain preceding emesis and fever
followed by crampy pain of hyperperistalsis
# anorexia, low grade fever, constipation, diarrhea(infrequent), urinary frequency, urgency
# perforation
;
*usually over 36-48hr from onset
of symptom
;
if delayed over 36-48hr, *65% perforation rate
; risk factors
ii) fecaliths
iii) young age
iv) 36O ÀÌ»óÀÇ temp.
v) WBC ¡è : 14,000 ¡è
vi) (+) family Hx. of appendicitis
Hx. pallor, flushing, physical activity, abd. movement
pulse rate & rectal temp.°üÂû
Diagnosis
Physical Examination
; inspection : swelling, movement of abdomen, pain on coughing
; maximal tender point
- older CH : McBurney point
- young CH : right iliac fossa
; rebound tenderness : needlessly painful sign
; Psoas sign : post. situated appendix½Ã Lt. side·Î ´¯È÷°í hip extension½Ã pain
; *¡ãimportant physical sign
-
*persistent direct tenderness to
palpation and rigidity of overlying rectus muscles
constant localized significant degree of tenderness
¸ÕÀú abd. exam.ÈÄ general exam. -> ¸¶Áö¸· recta exam.
ƯÈ÷ very young female adolescent
equivocal ÇÑ °æ¿ì 4-6½Ã°£ÈÄ reexam.¿äÇÔ.
. 15%¿¡¼ normal appendectomy
Auscultation : n'l or hyperactive -> hypoactive bowel sound
Laboratory Findings
1. CBC : leukocytosis : neutrophilia with left shifting, eosinophil ¡é
2. U/A : pyuria ; ureter & bladder °¡±î¿î app.½Ã
WBC 30/HPF RBC 20/HPF±îÁö
3. X-ray i) small bowel distension or obstruction
ii) calcified appendicolith
iii) soft tissue mass effect
iv) scoliosis concave to the Rt. side
v) paralytic ileus
4. Graded compression ultrasound
Ix. i) accurate tool to diagnose nonperforated app. (edematous & enlarged app.)
ii) perforation & abscess formation
iii) ileocecal enteritis -> RLQ pain½Ã appe. R/O °¡´É
(bacterial ileocecitis½Ã terminal ileum°ú cecumÀÇ
mural thickening°ú enlarged mesenteric LN)
5. Barium enema or abdominal CT
Differential Diagnosis
1. enteric inf. : Y. enterocolitica, campylobacter jejuni
2. acute flare up of crohn's ds
3. intussusception in older CH
4. Meckel diverticulum
5. mesenteric adenitis
6. generalized viral infection : midabd. pain, eating½Ã ¾ÇÈ, neutropenia
7. RLL pneumonia
8. UTI
9. DKA
10. bleeding from Rt. ovary, graafian follicle, torsion of undescended of testis
11. primary peritonitis
12. hematologic ds.: leukemia (esp. in relapse), hemophilia, sickle cell ds. H-S purpura
13. constipation, meconium ileus
14.constipation
Treatment
1. emergency appendectomy for early acute appe.
2. localized app. abscess½Ã ext. drainage¿ì¼± -> ³ªÁß ¼ö¼ú
3. fluid replacement : generalized peritotitis½Ã fluid & E. balance±³Á¤
i) no sign of dehydration
Ringer lactated sol. : 5% of body Wt. (1/2 - ¼úÀü, 1/2 - ¼úÈÄ)
ii) dehydration sign (+) : 7% of body Wt.
iii) severe dehydration : 10-15% of body Wt.
¼ö¼úÀü adequate urine outputÀ¯Áö
4. antibiotics : rupture½Ã ¼ö¼úÀüºÎÅÍ
triple (aminoglycoside + ampicillin + clindamycin/metronidazole/new cepha)
for 7-10 days
Px : good ; mortality 0.5-1%
¡ÚComplication
; 25-30%
1) wound inf.
;
*¡ãcommon postop. Cx.
; perforation½Ã 10-15%, no perforation½Ã 0-2%
2) pelvic, subphrenic, intraabdominal abscess
; ´ë°³ pelvic abscess´Â adj. bowel·Î ruptureµÇ¾î resolve
; subphrenic abscess´Â surgical drainage
3) liver abscess
4) prolonged paralytic ileus
5) intestinal obst. (postop.)
; 30Àϳ» ¹ß»ý .... nonop. management
; 30ÀÏÈÄ ¹ß»ý ... ischemia Áõ°Å(-)½Ã 48hr nasogastric tube·Î decomp. È¿°ú¾øÀ¸¸é laparotomy
6) volvulus
7) infertility
Appendix & chr. abd. pain
fibrous band, worm, fecalith ¿¡ ÀÇÇØ obst. of appe.
... important cause of recurre or chr. abd. pain
DDx.
1. urinary tract pathology
2. GI malfunction
3. psycholphysiologic pain
4. hereditary angioedema
5. porphyria
6. familial Mediterranean fever
Chapter 290. Surgical Condition Of The Anus, Rectum, And Colon Close Observation Of Anal Area
290.1 Anal Fissure
small laceration of mucocutaneous junction
C/M
: Hx. of constipation
pain on defecation
bright red blood on stool
skin tag
Tx. : Spontaneous healing ¼öÀÏ-¼öÁÖ, stool softener
290.2 Perianal Abscess and Fistula
# Two Different Groups
1) infants with no predisposing conditions
2) older children with predisposing conditions
Infants With No Predisposing Conditions
;
*relatively common
;
*infants usually boys younger than
2yr
; drain through orifice in the perianal area
; *disappear fistula before 2yr
Older Children With Predisposing Conditions
; older than 2yr with predisposing illness
- drug-induced or autoimmune neutropenia, Leukemia, AIDS, DM, Crohn disease, prior rectal surgery (Hirschsprung ds. imperforated anus), sequelae from immunosuppresants
Causative agents : mixed
aerobic : E. coli, Klebsiella pneumonia, S. aureus
anaerobic : Bacteroides, Clostridium vellionella
Clinical Manifestation
: low grade fever, mild rectal pain, perianal cellulitis, pustule, drain
Treatment
# infants
;
*not require any treatment
; uncomfortable infants
- I & D
; chronic fistula
- fistulotomy under general anesthesia
# older children
; wide excision & drainage & antibiotics
290.3 Hemorrhoids
: uncommon, benign, suspect portal hypertension
290.4 Rectal prolapse
; Exteriorization of the rectal mucosa through the anus
; procidentia
- extrusion of all the layer of wall
; onset age : 1-5yrs(mean, 3yr)
; ¡ÚPredisposing
Factor
- intestinal parasites, malnutrition, acute diarrhea, UC, pertussis, Ehlers-Danlos syndrome, meningocele, cystic fibrosis, chr. constipation, postop. for imperforate anus
; Clinical Manifestation
- painless, mild discomfort
- protruding mass from bright red to dark red, so long as 10-12cm
; Treatment
- manual & surgical reduction, stool softener
290.5. Pilonidal Sinus and Abscess
dimple located in midline intergluteal cleft, at level of coccyx
Chapter 291. Tumors Of Digestive Tract
Juvenile Colonic Polyp (Retention Polyp, Inflammatory Polyp)
TMC tumor of bowel in CH, malignant potential
rare, 1¼¼ ÀÌÈÄ ³ªÅ¸³ª¸ç, 15¼¼ ÀÌÈÄ less 21¼¼ ÀÌÀüÀÇ 3-4%
site : prox. to descending colon (40%)
1/2ÀÌ»ó 2 or more erythematous friable, pedunculated
size : 0.5mm-3cm, mucus-filled cystic gland simple layer of epithelium
C/M painless rectal bleeding, IDA
crampy abd. pain if intussusception or prolapse
´ë°³ spontaneous infarction & shedding
DDx.
i) other form of polyposis (esp. familial)
ii) Meckel's diverticulum
iii) fissure
iv) infection, colitis
v) coagulation disorders
Dx.
I) rectal exam : 1/3
ii) sigmoidoscopy : smooth pedunculated lesion
iii) air contrast barium enema
iv) fibroptic colonoscopy
v) saline enema with ultra
Tx. - Removal of polyp
Px. - recurrence ¶§¶§·Î
Familial Polyposis Syndrome
Familial Adenomatous Polyposis Coli
;
*premalignant condition
; adenomatous lesion in distal large bowel
; late in the 1st decade or teens
--> adenoma in 2nd or 3rd decades of life
;
*APC(adenomatous polyposis coli)
gene
-
*on long arm of chromosome 5
; Clinical Manifestation
- initially asymptomatic
- hematochezia, crampy pain, diarrhea (rare)
; Diagnosis
- family Hx.
- double contrast barium enema
- colonoscopy : biopsy
; child with family Hx of APC
-
*colonoscopy annually after 10yr
of age
; Treatment
- genetic counselling, pancolectomy
Peuts-Jegher Syndrome
;
*dominant inheritance, not
premalignant
; mucosal pigmentation of lip & gum, harmatoma of stomach & small bowel
; 50% - no family history
; up to 50%
- cancer in middle-aged adults
-
*not GI tract, not harmatoma
Gardner Syndrome
;
dominant inherited, *premalignant
;
*multiple intestinal polyps &
tumors of soft tissue and bone, particularly mandible
; additional features
- dental abnormalities, bilat. pigmented lesions in the ocular fundus, extracolonic cancers (hepatoblastoma, CNS)
Hemangioma Of Intestine
painless bleeding : subtle, sudden, massive
50% cutaneous hemangiomaµ¿¹Ý
Leiomyoma
stomach, jejunum¿¡ ½ÃÀÛ
Carcinoma
* adenoca. predisposing lesions in gut
¨ç familial polyposis syndrome
¨è Gardner synd.
¨é idiopathic ulcerative colitis
¨ê Crohn's ds -+
¨ë chromosomal breaks°ü·Ã disorder -+- lesser
tumor´Â ´ë°³ adult½Ã
site : colon
C/M : ill health, abd. pain & mass, hemorrhage
Á¾Á¾ undifferentiated & highly malignant
Lymphosarcoma Of Intestine
childrenÀÇ digestive tractÀÇ malignancy´Â ´ë°³ lymphosar. TMC
site : lower SI
C/M : ill health, abd. pain, anemia
longstanding celiac ds.½Ã ¡è
Carcinoid Tumors
; enterochromaffin cellÀÇ tumor
; appendix¿¡ common, low grade malignancy, resectionÈÄ recur´Â rare
; Clinical Manifestation
- carcinoid syndrome
- appendix¿ÜÀÇ tumor´Â metastasisÀß ÀÏÀ¸ÄÑ pharmacologically active secretion
-
*episodic intestinal hypermotility
& diarrhea
- vasomotor disturbances
- bronchoconstriction
; *¡ãimportant active agent
: serotonin
; Diagnosis
- urinary 5-hydroxyindoleacetic acid
291.1 Diarrhea From Hormon-Secreting
C/M : massive diarrhea, fluid & electrolyte imbalance, Wt. loss,
Dx. presence of secretory watery diarrhea, extraintestinal manifestation
measurement of suspect hormone or metabolic serum or urine
various imaging technique
Tx. resection or hormone antagonist
¡ÚTable 291-1
Diarrhea Caused by
Hormone-Secreating Tumors
Nodular Lymphoid Hyperplasia
lymphoid follicles in the lamina propria of the gut in Peyer's patches
submucosal nodules
causes of diffuse SI nodular lymphoid hyperplasia :
immunoglobulin deficiency w/wo Giardia lamblia infection
Sx. rectal bleeding, diarrhea, abdominal cramps beginning by 3 yrs
resolves spontaneously
require no specific Tx.
Chapter 292. Inguinal Hernia
; *¡ãcommon condition requiring op. in the pediatric age
; incidence
- 10-20/1,000
- M:F=4:1
- 50% < 1yrs(most 6 Mo)
; *indirect
inguinal hernia > direct inguinal hernia(1%), femoral hernia
; *Rt.
side(60%) Lt.(30%) both(10%)
; *prematurity½Ã 30%
Embryology & Pathogenesis
;
*persistent patency of processes
vaginalis
cf) hydrocele : obliteration prox. & patency distally
¡ÚFig.
291-1
Clinical Manifestation
bulge in the inguinal region and extended toward or into the scrotum only
during crying or straining
swelling of the scrotum
discomfort
intestinal obs. abd. distension, vomiting
Diagnosis
careful Hx.
index finger manifulation : unnecessary
infant lie supine with extended legs and arm over heads-bulge & swelling
older children standing
rectal exam.
transillumination
silk sign palaption of spermatic cord over pubic tubercle
# ¡ÚRisk
Factor
; positive family Hx. of hernia, cystic fibrosis, CDH, undescended testis, ambiguous genitalia, hypospadia, epispadia, ascites, congenital wall defects
; connective tissue disorder as Ehlers-Danlos SD, Mucopolysaccharides
;
*testicular femminization
-
*50%ÀÌ»óÀÌ inguinal herniaÀ» °¡Áö¹Ç·Î female with inguinal hernia´Â ¹Ýµå½Ã
°í·Á
Treatment
; operative repair
- Tx of choice
- not resolving spontaneoulyÀ̹ǷΠ1¼¼ÀÌÀü¿¡ elective operation
; contralat. op. ³²¾Æ´Â 1¼¼ÀÌÇÏ, ¿©¾Æ´Â 2¼¼ ÀÌÇÏ, 2¼¼ ÀÌÇÏÀÇ Lt. side H.
not op. Ix. isolated hydrocele (hydrocele of tunica vaginalis)
Complication
incaceration 9-20% in 1st year higher in female, premature
need to emergency op. : reduction 24-48½Ã°£³» elective
method to reduce incacerated inguinal hernias
- sedation by barbiturate, chloral hydrate
placing in Trendelenburg position
not use ice pack
strangulation
Richter hernia : intestineÀÇ antimesenteric portionÀÌ incacerationµÇÁö¸¸
intestineÀÇ obstructionÀº ¾ø´Â °æ¿ì
premature infant higher incidence & incaceration
Prognosis
postop. Cx. 2% : wound infection 1%
recurrence rate < 1%
section 5. exocrine pancreas
Chapter 293. Embryology, Anatomy, And Physiology
293.1 Anatomic Abnormalities
Pancreas divisum
;
*¡ãcommon anomaly
; failure of dorsal and ventral pancreatic anlagen to fuse
--> tail, body, head of pancrease drain through small accessory duct of Santorini
; recurrent pancreatitis
; Treatment
- endoscopic insertion of an endoprosthesis
Chapter 294. Pancreatic Function Tests
# ¡ÚBentriomide
(N-benzoyl-L-tyrosyl-p-aminobenzoic acid, Chymex)
; synthetic tripeptide for noninvasive testing of pancreatic enzyme function
;
cleaved by chymotrypsin --> releasing *para-aminobenxoic
acid (PABA)
; measured at 90min in serum specimen
Chapter 295. Disorders Of The Exocrine Pancreas
Disorders Associated With Pancreatic Insufficiency
Cystic Fibrosis
Shwachmann-Diamond Syndrome
Isolated Enzyme Deficiencies
Syndromes Associated With Pancreatic Insufficiency
Chapter 297. Pancreatitis
Pathogenesis
Clinical Manifestation
;
*abdominal pain, persistent
vomiting, fever
; pain
- epigastric, steady
- resulting in antalgic position : hips & knees flexed, sitting upright or lying on the side
- increase in intensity for 24-48hr
- time vomiting increase
Diagnosis
Treatment
Prognosis
297.1 Chronic Pancreatitis
¡ÚEtiology
; hereditary pancreatitis
; idiopathic congenital anomalies of ductal systems
;
*hyperlipidemia(type I, IV, V)
;
*hyperparathyroidism
; ascariasis
; cystic fibrosis
Diagnosis
# ¡ÚERCP
;
*any child with idiopathic
nonresolving, recurrent pancreatitis