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CASE PRESENTATION

IMAD ZAFARM09107

Case History along with hospital course

Differentials Investigations Pathophysiology of the disease

Contents

2 years old boy presented to the ER on 2nd February 2014 with complaints of Per rectal bleeding for 4 days

accompanied by Abdominal pain Increased irritability Poor feeding

Presenting Illness

Child was in usual state of health 4 days back, when he developed abdominal pain and started passing stool mixed with fresh blood and clots.

Blood was ½ a cup in quantity and 2-3 episodes per day.

Not associated with fever, vomiting, oral bleeding or bleeding from any other orifice.

Decreased oral intake and irritability. Taken to a local hospital in Hyderabad

where his Hgb came out to be 2.7 and he was transfused packed cells and platelets.

His condition did not improve and he was referred to AKUH for further management.History of Presenting

Illness

Birth History- unremarkable (SVD, term).

Immunization- Up to date(acc. to mother).

Nutrition- Regular diet. Developmentally- Normal. All

milestones reached on time. Family History- Unremarkable. Drug History- Unremarkable, no

allergies known.

HOPI(contd.)

General examination- Irritable child with pallor.

Cardiovascular Examination- Decreased peripheral perfusion, rest of examination unremarkable.

Respiratory- Unremarkable. Abdominal Examination- Soft, non

tender; Rectal examination not done; Gut sounds audible.

CNS- Grossly intact.

O/E

Intussusception Meckel’s diverticulum Rectal polyps Infectious colitis Anal fissure

Differential Diagnosis

Diagnosis Frequency Symptoms TherapyIntussusception 1/2000 Bilious

vomiting, ‘currant jelly’ stools, intermittent abdominal pain

Radiological, Surgery

Meckel’s Diverticulum

2/100 Rectal bleeding, abdominal pain

Surgery

Rectal polyps 6/100 Rectal bleeding, fatigue, constipation.

Surgery

Infectious colitis

Incidence- 10/100,000

Fever, bloating, diarrhea, abdominal pain

Antibiotics

Anal fissure 1/350 Rectal bleeding, pain during defecation

Medical, surgery

HGb: 5.3 Hct: 17.5 Platelets: 186 TLC: 8.8

Neutrophils: 57.8 Lymphocytes: 27.3

BUN: 12 CR: 0.6 Sodium: 135 Potassium: 3.5 PT: 10.2 APTT: 17.2 SGOT: 35

Initial Investigations

Ultrasound abdomen- Unremarkable showing no evidence of Intussusception

Meckel’s Scan: positive; showing evidence of heterotopic gastric mucosa in abdomen.

Radiological investigation

02/05/14: Patient was planned for Laprotomy plus wedge resection plus Inverted appendectomy.

Meckel’s diverticulum was confirmed at 35 cm proximal to ileocecal junction. Two intussusceptions ileocecal <5cms. Dilated proximal bowel.

Intussusception reduced. Meckel’s diverticulum divided and inverted appendectomy was done, cavity washed with saline.

Post operative management plan IV analgesics IV fluids IV antibiotics NG tube inserted

Remnant of the embryonic omphalo-mesenteric duct(yolk sac to mid gut lumen)

Fails to obliterate in the 7th week of gestation.

Located on the anti-mesenteric border of the ileum; 2 feet proximal to the ileocecal valve.

True diverticulum; mucosa, sub mucosa, muscularis propria.

Gastric mucosa(50%), Pancreatic(6%).

Pathophysiology

Rule of 2: 2% of the population 2 inches in length 2 feet proximal to the ileocecal valve 2 types of common ectopic tissue (gastric or

pancreatic) 2 years is the most common age at presentation Male to female 2:1

Asymptomatic Rectal bleeding Abdominal pain(clinically identical to

appendicitis) Intestinal obstruction Perforation

Clincial Presentation

Technetium Pertechnetate scan (Meckel Scan) – Gold standard.

Barium follow through or small bowel enema

CT scan

Diagnosis

Surgery in all cases Laparotomy or

laparoscopy/laparoscopic assisted bowel resection.

If the bass is narrow and no mass present in the lumen of the diverticulum, a wedge resection of the diverticulum or a simple diverticulectomy can be performed.

If a mass is palpable, base is wide or when there is inflammation, a segmental resection of the bowel followed by end-to-end ileo-ileostomy is preferred. Treatment

Hemorrhage Intussusception Volvulus Diverticulitis Peritonitis Incarcerate into a Hernia(Littre’s

hernia) Tumors(carcinoid) – rare(0.5-2%)

Complications

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