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Case 1 A 1-day-old male infantpresentswithdifficulty in feedingandbreathing.Theparentsreport that the babyhasbeenchoking andcoughing during feeds, andhasbeenhavingincreased episodes of vomiting.Theyalsonotethat thebabyhasnot passedanystools sincebirth.Onexamination, the babyisdrooling, using accessory muscles to breathandanNGtubecannotbepassed.Case 1 Based onthepresentation,whatisthemost likely diagnosis? A) Oesophageal atresia B) Midgutvolvulus C) Hirschsprungdisease D) IBD E) Pyloricstenosis https://www.nhs.uk/conditions/oesophageal-atresia/Case 1 What imaging modality isused most commonly todiagnoseoesophageal atresia? A) Ultrasound B) CT scan C) MRI D) Endoscopy E) Plainradiograph Casecourtesyof HenryKnipe, Radiopaedia.org,rID: 41467 Types of oesophageal atresia ParoliniF, BulottaAL, BattagliaS,AlbertiD.Preoperativemanagementof childrenwithesophagealatresia: current perspectives.PediatricHealth Med Ther.2017;8:1-7. https://doi.org/10.2147/PHMT.S106643 Oesophageal atresia Signs and Symptoms Riskfactors Investigations Treatment Complications -Increased secretions -Maternalsmoking -Chest Xrays =gasfilled -Surgery:anastomosis -Anastomoticleaks -Recurrent vomiting duringpregnancy stomach inthepresence -Reflux -Drooling -Chocking during feeds -Maternalalcohol offistula, NGtubehighin -IV antibiotics -Strictures -Respiratory distress consumption oesophagus -IV fluids -Recurrent aspirationpneumonia -Increased maternal age -TPN -Inability to passNGtube -Certaingenetic -(Fluoroscopy) -Nil bymouth -Distended abdomen syndromessuch as VACTERLassociation.Case 2 4-week-old maleinfantpresentsto ED witha historyofprojectile non-biliousvomiting afterfeeds. He wasbornat term withabirthweightof 3.2kg and is exclusively breastfed.Thevomitinghas progressively worsenedoverthepastweek, andthe infanthad stopped gainingweight.Onexamination, the infantappeared dehydrated, and his abdomen was visiblydistended.Case 2 Bloods show hypochloraemic, hypokalaemic alkalosis. Giventhepresentation,whatisthe most likely diagnosis? A) Duodenal atresia B) Colonic volvulus C) Hirschsprung disease D) IBD E) Pyloricstenosis https://zerotofinals.com/paediatrics/gastro/pyloricstenosis/Case 2 What istheprimary diagnosticimagingfor pyloric stenosis? A) Abdominal ultrasound B) Bariumswallow C) Abdominal radiography D) Upper endoscopy E) CT scan Casecourtesyof LaughlinDawes, Radiopaedia.org,rID: 8142Case 2 What isthemainstay oftreatment forpyloric stenosis? A) Nasogastric tubeinsertion B) Antibiotics C) Ramstedt pyloromyotomy D) Intravenous fluids E) ERCP https://www.mayoclinic.org/diseases-conditions/pyloric- stenosis/multimedia/pyloromyotomy/img-20006399 Pyloric stenosis Signs and Symptoms Riskfactors Investigations Treatment Complications -'Projectile’non-bilious -Males -Bloods: FBC, CRP,Capillary -Surgery: Ramstedt -Dehydration vomiting,typically30 minutes -2to 4weeks old bloodgas,Blood cultures pyloromyotomy -Malnutrition after afeed -Positive FH -Failure tothrive -Dehydration -First born -Urinalysis -A palpable mass may be presentin the upperabdomen -Abdominal USS -Hypochloraemic,hypokalaemic alkalosisCase 3 3 days old baby present with suddenonsetbilious vomiting and inconsolableabdominal pain. On examination, theabdomenis not distendedandthe baby’s observations arestable. Giventhelikely diagnosis, which imaging modality isthegold standardforthis condition? A)Abdominal X rays B)CTscan C)Upper GI contrast studies D) MRI E)USSCase 3 Fromthe upper GI contrast study, you get the image onthe right. What is the diagnosis? A)Midgutvolvulus B) Pyloric stenosis C) Crohn’s disease D) Hirschsprung disease E) Oesophageal atresia https://bestpractice.bmj.com/topics/en-gb/753/investigations Midgut volvulus Signs and Symptoms Riskfactors Investigations Treatment Complications -Sudden onset severe abdominal pain -1month to1year old -Upper GI contraststudies: EmergencyLadd’s -Necrotisingenterocolitis -Sudden onset bilious vomiting -Disruption tointestinal rotation gold standard procedure -Shortbowelsyndrome -Child isinconsolable and fixation -Complicationsofsurgery Late signs: -Abdominal wall defects (i.e., -WBC elevated -Bowelobstruction -Tachycardia gastroschisis, omphalocele) -Sepsis -Tachypnoea -Congenital diaphragmatic -Blood gas: metabolic -Abdominaltendernessand hernia acidosis distension -Acidosis -Signs ofperitonitis andshock -Blood in stoolsCase 4 4-month-old female infant presented with jaundice since birth. Herskin andeyes are turning yellow. She isnotfeeding andnot growing. Given the likely diagnosis, which of these laboratory tests do you think will be abnormally elevated? A)TFT B) Albumin C) Amylase D) Conjugated bilirubin E) ESRCase 4 LFTs were foundto beraised and conjugated bilirubin was abnormally high. Liver USS showed biliary tree abnormalities. Biliary atresia is suspected. What isthe gold standard investigation todiagnose this condition? A)CTscan B)AbdominalX rays C) Liver biopsy D) MRI E) ERCP Biliary atresia Signs and Symptoms Riskfactors Investigations Treatment Complications -Jaundice -Female -LFTs -Surgery: Kasai -Liverfailure -Poorappetite -Prematurity -Bilirubin: conjugated portoenterostomy -Complications of -Darkurineturbance -FH bilirubin isabnormally surgery -Pale stools high -Kernicterus -Hepatomegaly+/- -(Serumalpha 1- splenomegaly antitrypsin) -(Sweat chloridetest) -USS -Liverbiopsy: gold standardA note on Jaundice First 24hof life 2-14 daysof life >14 days of life (>21 for premature) Always pathological Physiological Breastfeedingorpathological - Rhesus haemolytic disease Morecommonin breastfedbabies -Biliary atresia -ABO haemolytic disease Duetomoreredbloodcells, more -Hypothyroidism -Hereditary spherocytosis fragileredblood cellsandless -Galactosaemia -Glucose-6-phosphodehydrogenase developed liverfunction. -Metabolicdisorders -Urinary tractinfection -Congenitalinfections:CMV, toxoplasmosisCase 5 A 3-week-old premature infantisadmitted to the neonatal unitwithfeedingintolerance, abdominal distension,andbloody stools. He weighted 1.4kg atbirthandsuffered from respiratory distresssyndrome forwhichhe received mechanical ventilation. An abdominal X rayisarranged urgently. Case 5 What typical signcan yousee intheabdominal X rays onthe right(arrowed)? A) Thumbprinting B) Rigler’s sign C) Football sign D) Pneumatosis intestinalis E) Sail sign Casecourtesyof HaniMakkyAl Salam, Radiopaedia.org,rID: 9793Case 5 Based onthepresentation andfindings, whatis the most likely diagnosis? A) Intussusception B) Meconiumileus C) Necrotizingenterocolitis D) Hirschsprung's disease E) Pyloricstenosis Casecourtesyof HaniMakkyAl Salam, Radiopaedia.org,rID: 9793 Necrotising Enterocolitis Signs and Riskfactors Investigations Treatment Complications Symptoms -Intolerancetofeeds -Low birth weightor very -Bloods: FBC, CRP, SURGICAL -Perforationandperitonitis -Vomiting,particularly premature Capillary bloodgas, EMERGENCY:resection -Sepsis withgreenbile -Formula feeds Blood cultures -Death -Generallyunwell, -Respiratorydistressand -Nil bymouth -Strictures lethargic -Distended,tender assisted ventilation -Urinalysis -IV fluids -Abscessformation abdomen -Sepsis -TPN -Longtermstoma -Absentbowelsounds -Patientductus arteriosusand -Abdominal Xrays: -IV Antibiotics -Short bowel syndromeafter -Bloodinstools othercongenitalheart disease pneumatosis intestinalis -NGtube surgeryCase 6 A 6-month-old male infantpresentsto the emergency department withsudden onsetof colicky abdominalpain, vomiting,andbloody stool. Theinfantappears lethargic and hasa ‘sausage-shaped’ palpable massintheright upper quadrant oftheabdomenwithvisible peristalsis.Case 6 From theinitialpresentationyoususpect intussusception. What istheimaging ofchoice for thiscondition? A) Abdominal X-ray B) Ultrasound C) CT scan D) MRI E) PET-CTCase 6 What typical signcan yousee onUSS? A) Rigler’s sign B) Targetsign C) Double duct sign D) Lead pipe sign E) Sail sign CasecourtesyofMaulik S Patel, Radiopaedia.org,rID: 9265tussusception Intussusception Signs and Symptoms Riskfactors Investigations Treatment Complications -Severe,colickyabdominal -Males -Bloods: FBC, CRP,Capillary -Reduction byair -Obstruction pain -Recent orcurrentviral bloodgas,Blood cultures insufflation/air enema -Gangrenousbowel -Pale,lethargicand unwell infection underradiological control -Perforation child -Urinalysis (ileo-caecal only) -Death -“Redcurrantjellystool” -Rightupper quadrant -Abdominal USS: target -Surgical reduction “sausage-shaped”mass sign -Vomiting -IntestinalobstructionCase 7 3-day oldbabypresentswithabdominal distensionandpoor feeding. Heisstilltopass meconium. What isthemostlikely diagnosis? A) Cystic fibrosis B) Necrotisingenterocolitis C) Coeliac disease D) Inflammatory boweldisease E) HirschsprungdiseaseCase 7 Which of thefollowing isthegold standard diagnostic testforHirschsprungdisease? A) Abdominal X-ray B) Rectal biopsy C) Bariumenema D) CT scan E) MRI https://teachmepaediatrics.com/surgery/abdominal/hirschsprungs-disease/Case 7 What istheINITIALmanagement of Hirschsprung’sdisease? A) Surgery B) IV antibiotics C) Bowelirrigation D) Laxatives E) Dairyfreediet Hirschsprung’s disease Signs and Symptoms Riskfactors Investigations Treatment Complications -Neonates:failuretopass -Males -Abdominal Xrays -INITIAL:Bowel -Hirschsprung’s meconium -Down’s syndrome -Contrast enema irrigation associated enterocolitis -Infants:chronicconstipation, -FH failureto thrive,and -Rectalbiopsy: gold -DEFINITIVE:Surgical abdominaldistension standard resection -Olderchildren:chronic constipation,abdominal distension,and poorweight gain