August 2, 2013

Image of the Day 23: Progressive Constipation in a 1 year 11 months child

1 year 11 month boy presented with progressive history of minimal bowel opening for the past 1 year with on and off abdominal pain. Still able to pass flatus and minimal amount of feces. Child otherwise active and tolerating orally.

On examination, child is active, well and not toxic looking. vital signs are normal. Abdomen is distended but soft. Bowel sound present. Per rectal reveal impacted stool. No blood or mucous present

Abdominal X Ray shows dilated large bowel (proximal region) with no air in the rectum region. Fecal impaction was seen at the region of ascending colon. No air fluid level is seen.

Based on the history, physical examination and abdominal X ray, surgical team was consulted and the impression is TRO Hirschsprung's disease.

Hirschsprung's disease is due to absence of Auerbach (myenteric) and Meissner (sub mucosal ganglion cells) plexus of the large colon and may affect variable length of large colon. This will cause reduce peristaltic bowel movement in the affected bowel segment. This will usually cause mega colon of the bowel proximal to the lesion and collapsed bowel distal to the lesion.

Early presentation are observed in newborns and infants like fail to pass meconium shortly after birth, fail to pass first stool within 24-48 hours of life, jaundice, poor feeding, poor weight gain, vomiting, watery diarrhea and infrequent but explosive stool

Older child may presented with gradually worsening of constipation, fecal impaction, distended abdomen, malnutrition, or failure to thrive.

Child is best to be admitted to exclude other diagnosis especially acute abdomen. Bowel preparation should be done and rectal wash put can be performed.

Rectal biopsy is a diagnostic test and once confirmed positive of Hirschsprung's disease, a laparotomy with bowel resection of aganglionic region with end to end anastomosis or colostomy can be performed.

No comments:

Post a Comment

Ya Allah! Permudahkanlah aku untuk menuntut ilmuMu, memahaminya, mengingati dan menyebarkannya. Berkatilah ilmu itu dan tambahkanlah ia. Amin.