an unusual cause of colic

An unusual cause of An unusual cause of coliccolic

Dr Yasser NegmDr Yasser NegmSpR of Paediatric GastroenterologySpR of Paediatric Gastroenterology

Great Ormond Street Great Ormond Street HospitalHospital

04/10/23

E LE L Female

DOB: 22.11.02

Ethnic origin: White British

Healthy parents

Born: - At full term - Normal delivery - No antenatal events - Birth weight: 3.9 Kg - Passed meconium within 24 hours

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SymptomsSymptoms

Started since birth. Persistent discomfort during feeding. Frequent vomiting. Frequent foul smelling loose stools. Breast feeding stopped at the age of 1 week. Cow’s milk formula Soya milk

No improvement

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Paediatrician at the age of 3 months.

Pepti junior

Neocate

Normal stools, no vomiting

Night only: 4 – 20 times- Screaming- Arching

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Normal examinationNormal examination

Normal developmentNormal development

Normal growthNormal growth

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At 5 months: Started on Ranitidine, Domperidone& Omeprazole

No improvement

- PH study : couldn’t be completed

- Barium study: Normal

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- Admitted for assessment: Continues to scream at night only, behaving like breath-holding

ENT Normal

Midazolam Referrral

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Any further investigations/ Any further investigations/ Treatment at DGH levelTreatment at DGH level

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Differential diagnosisDifferential diagnosis

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GOSHGOSH11/200311/2003

1 year old1 year old Still satisfactory growth

Normal examination

Initial management: - Dietary changes - Dose timing changes - Immunoglobulins and

subclasses - SIgE for food screen

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Tissue transglutaminase antibodies NEGATIVE

Total IgE 23.4 kU/L 0 - 32

EGG WHITE <0.35 COW'S MILK <0.35 WHEAT <0.35 SOYA BEAN <0.35

IgG 10.80 G/L 4.9 - 16.1 IgA 1.32 G/L 0.4 - 2.0 IgM 1.15 G/L 0.5 - 2.0

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InvestigationsInvestigations

EndoscopyEndoscopy: Mild chronic gastritis, duodenitis: Mild chronic gastritis, duodenitis

Upper GI seriesUpper GI series: Gastro-oesophageal reflux : Gastro-oesophageal reflux (GORD), no malrotation(GORD), no malrotation

PH studyPH study: GORD: GORD

EGG (Electrogastrogram):EGG (Electrogastrogram):

Suggestive of atopySuggestive of atopy

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11/200411/20042 years old2 years old

Still no improvement (Even worse during daytime) in spite of:

- Dietary exclusions- Increasing doses of Domperidone, Ranitidine &

Omeprazole/Lansoprazole to maximum.- Trials of Sulphasalazine, Cromoglycate, Cetirizine,

Ketotifen & even steroids (Possible colitis)

Described as “picky eater”, but still excellent growth

( 91st centile for both wt. & ht.)

Dry cough for 3 days/4-6 weeks (Reflux??)

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Parents completely exhausted: Waking up 10-20 Parents completely exhausted: Waking up 10-20 times/nighttimes/night

Tried on Cisipride, DicyclomineTried on Cisipride, Dicyclomine

New PH study, milk scan, abdominal U/S: NormalNew PH study, milk scan, abdominal U/S: Normal

Repeat endoscopy: Inactive mild gastritisRepeat endoscopy: Inactive mild gastritis

Allergy clinic: Supported diagnosis of allergic Allergy clinic: Supported diagnosis of allergic enterocolitis, exclusion of wheat/dairy/egg/soya and enterocolitis, exclusion of wheat/dairy/egg/soya and same medicationssame medications

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Another PH study: NormalAnother PH study: Normal

Mebeverine, peppermint oilMebeverine, peppermint oil

Barium follow-through:Barium follow-through: - - Position of the caecum?

Discussed in x-ray meeting: Probably mobile

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Symptoms get worse when eats wheat “moaning, tossing& turning in bed”

Montelukast added

A trial of Metronidazole

Urine for Bacterial overgrowth

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Urine test for bacterial Urine test for bacterial overgrowthovergrowth

D-lactic acid levels differentiate bacterial overgrowth D-lactic acid levels differentiate bacterial overgrowth syndrome from other metabolic causes. syndrome from other metabolic causes.

The D isomer of arabinitol is elevated in patients with invasive candidiasis

P-Hydroxybenzoate, p-Hydroxyphenylacetate and P-Hydroxybenzoate, p-Hydroxyphenylacetate and Tricarballylate Tricarballylate are produced by microbial action on are produced by microbial action on tyrosine and phenylalanine and are markers of tyrosine and phenylalanine and are markers of bacterial growth in the gut.bacterial growth in the gut.

Pizzorno and Murray, Organic Compounds in Urine - Natural Medicine (1998), Churchill Livingstone, London

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Surgical referralSurgical referral

Surgical cause of abdominal pain??

Differential diagnosis of volvulus hernia

Meckels ovarian gallbladder appendix

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LaparoscopyLaparoscopy

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Laparoscopic CaecopexyLaparoscopic Caecopexy

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3 months post-op Pain disappeared completely Good energy levels Regular school attendance Still wakes once or twice/night

Funny taste in her mouth

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SLSL Female

DOB: 11.10.06

First week of life: - Screaming - Agitation - Abdominal distension - Vomiting - Loose stools

Growing well

Treated as GORD, food allergy

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InvestigationsInvestigations

PH study: 5% GORD

Barium follow-through: - No delay in gastric emptying - DJ flexure in midline - Small bowel predominantly on the right

Normal endoscopy

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Surgical referralSurgical referral

SiblingSibling

Upper GI contrast : DJ flexure in Upper GI contrast : DJ flexure in midlinemidline

Caecum in right iliac Caecum in right iliac fossafossa

Proceeded to laparoscopyProceeded to laparoscopy

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Laparoscopic CaecopexyLaparoscopic Caecopexy

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The caecum is a section of the intestinal tract. It lies at the junction of the small and the large intestines and is the origin of the appendix.

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Congenital abnormalities of caecal fixation

Adhesions

Mobile caecum syndrome

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Congenital caecal adhesions/peritoneal bands

May cause chronic intermittent abdominal pain, especially if associated with mobile caecum

Many authors have described this association

A nodal pointA nodal point

Twist Twist

VolvulusVolvulus

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ELELBarium follow-Barium follow-

throughthrough

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SLSLBarium follow-Barium follow-

throughthrough

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Mobile Caecum Syndrome Mobile Caecum Syndrome (MCS)(MCS)

Abdominal pain due to improper attachment/detachment of the caecum to the rest of the bowel.

It is not clear what degree of detachment is enough to cause symptoms.

Can cause volvulus of the caecum which is uncommon

but serious and is distinct from MCS.

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Embryological origin of mobile Embryological origin of mobile caecumcaecum

An anatomic variation due to failure of An anatomic variation due to failure of right colon fusion with lateral right colon fusion with lateral peritoneum at 12 weeks of gestation. peritoneum at 12 weeks of gestation.

It affords the opportunity for free It affords the opportunity for free partial rotation of the caecum or partial rotation of the caecum or folding upon itself.folding upon itself.

As a result intermittent As a result intermittent intestinal sub intestinal sub

obstructionobstruction or volvulus or volvulus

(complete torsion)(complete torsion)

Tirol FT. Recurrent cecocolic torsion: “Phantom Tumor”. Abdm Surg 1999, Fall:20-24

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Epidemiology of mobile Epidemiology of mobile caecumcaecum

More commonly found in childrenMore commonly found in children(Incidentally during appendicectomy)(Incidentally during appendicectomy)

More commonly found in femalesMore commonly found in females(Especially during pregnancy)

10-15% of population in one study10-15% of population in one study

More common in African and Asian ethnic More common in African and Asian ethnic

groupsgroups

(Mcgraw JP et al. The Roentgen diagnosis of volvulus of the cecum. Surgery 1948;24: 793-804

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PresentationPresentation

Chronic abdominal pain Chronic abdominal pain (Right lower quadrant, commonly postprandial)

Constipation/diarrheaConstipation/diarrhea

Very similar to irritable bowel syndrome Very similar to irritable bowel syndrome

(IBS).(IBS).

Usually in an adult multipara female from a Usually in an adult multipara female from a tropical ethnic backgroundtropical ethnic background

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Caecal volvulusCaecal volvulus Axial twist of the bowel upon its mesentery. Misnomer as the terminal ileum and ascending colon

are usually involved.(Frimann-Dahl J. Volvulus of the right colon Acta Radiol (Stockh),

1954;41:141- 155)

Results in acute intestinal obstruction. May or may not be complicated by occlusion of the

mesenteric vessels Ischaemia First described by Rokitansky in 1837

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Baron Carl von RokitanskyBaron Carl von Rokitansky

19 February 1804 – 23 July 1878

A Bohemian physician, pathologist, humanist philosopher and liberal politician

First to describe “Superior mesenteric artery syndrome”

Warned against the abuse of "natural science liberties". Scientists should first regard humans as "conscious and free-willing subjects" and only then follow their urge toward knowledge.

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Caecal volvulusCaecal volvulus Extremely rare in children, more common in adults

Sex predilection variable in literature, but most report male predominance

Overall 3-7 cases/million/year

Geographical distribution variable(More common in Eastern Europe and Scandinavia)

Clinical picture of acute intestinal obstruction

Up to 40% mortality in children

(Ballantyne, GH et al. Volvulus of the colon. Incidence and mortality. Ann Surg 1985; 202:83)

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Association with other GI Association with other GI abnormalitiesabnormalities

Reported association with GORD (More with malrotation)

Reported association with food intolerances(Firor HV, Steiger E. Morbidity of rotational abnormalities of the gut beyond infancy. Cleve Clin Q

1983;50:303-309)

Definite aetiological correlation with all causes of intestinal distension and dysmotility

(Constipation, malabsorption, etc…)

(T Consorti, T H Liu. Diagnosis and treatment of caecal volvulus. Postgrad med j. 2005 December; 81(962): 772–776)

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Learning pointsLearning points

The 6 do nots:

- Do not turn down the parents’ voice.

- Do not under appreciate the significance of persistence.

- Do not rely fully on apparent well being.

- Do not give up finding clues in the history.

- Do not stop talking to other specialties.

- Do not think that invasive procedures have to be at the bottom of the work-up.

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I do thankI do thank

The mentor of this lecture: Dr Susan Hill, Consultant of Paediatric Gastroenterology

Mr David Drake, Consultant of Paediatric Surgery

Miss Kate Cross, Consultant of Paediatric Surgery

Miss Nishat Rahman, Specialist Registrar of Paediatric Surgery

Dr Katy Wessely, Clinical fellow of Radiology

The dynamo of the PGME summer lecture series: Jack Fairhall, Education Officer

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And I do thank you all And I do thank you all for your kind attentionfor your kind attention

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an unusual cause of colic

Health & Medicine

term normal delivery

vomiting night

frequent vomiting

improvement ph study

barium study

loose stools

egg white

frequent foul