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CASE 3

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  1. CASE 3 Meckel’s Diverticulum

  2. General Data • I.S. • 6 mos old • Female • Filipino • Roman Catholic • Pandacan, Manila

  3. CHIEF COMPLAINT: Bloody stools

  4. History of Present Illness • 4days PTC fever (T38.8C),Paracetamol drops no fever, cough, colds, vomiting good appetite and activity no consult • 2 days PTC persistence prompted consult with AMD, Dx: acute viral illness • 1 day PTC lysis of fever 2 episode of dark stools, irrritable, decrease in appetite ER : SFA ileus; no recurrence of stools Dx : AVI, resolving; t/c Milk Allergy

  5. History of Present Illness • Few hrs PTC 2 episode of voluminous maroon colored stools Admitted

  6. Review of System • General: (-) weight loss, anorexia, easy fatigability • HEENT: no trauma, no ear infection, • Neck: (-) limitation of motion, mass, adenopathy • Respiratory: (-) shortness of breath, easy fatigability, wheezing • Cardiology: (-) palpitation or cyanosis • Musculoskeletal: (-) swelling, deformities

  7. Past Medical History • No bronchial asthma • no Primary Tuberculosis infection • no known allergies • This is the patient’s first admission

  8. Family History • (+) Diabetes: maternal grandparents • (+) Hypothyroid : mother • No history of cancer

  9. Birth and Nutritional History • Born to a 34 year old G3P2, non-smoker, non-alcoholic beverage drinker, with regular prenatal check up • Denied illness during pregnancy • Born Full term via Repeat Ceasarian section at Cardinal Santos Medical Center • No fetomaternal complications • No history of Breastfeeding • Enfapro 6oz/bottle x 12 bottles/day • Complimentary feeding (Cerelac): 6 mos old

  10. Immunization

  11. Developmental History • Presently, sits with support

  12. Upon arrival ER • S>(+) maroon colored stool • O>pale looking, irritable HR 106 RR28 clear breath sounds soft abdomen, non tender good pulses • A>Lower GI bleed t/c Meckel’s Diverticulum • P>lab work up PRBC 10cc/kg post transfusion Hgb 10.6

  13. Laboratory Examination • CBC 7.7/23.4/9090/N16 L79 M5/170,000 • Retic count 0.35 • Stool Exam RBC 30-40 • Fecal occult Blood Positive • PT 10.4 INR 0.83 181% PTT 41.8 • Urinalysis <1.005 ph7.5 • PBS: microcytic hypochromic • Na 139 K 4.6 Cl 102 Ca 9.3

  14. Laboratory Exam • SFA non specific, non obstructive gas pattern • Meckel's Diverticulum Scintigraphy which showed radioactive activity on the right lower quadrant which may represent ectopic gastric mucosa.

  15. Upon arrival at PICU • s/p Explore Laparotomy, Resection of Meckel’s diverticulum with end to end anastomosis • OR findings: 1.5cm Meckel’s Diverticulum approx 25cm from appendix • Estimated Blood Loss <20cc • s/p 160 PRBC (20cc/kg) • P> NPO • D5NR x 40cc/hr • Cefazolin 250mg/IV (125mkd) • Ranitidine 10mg/IV q8 • Nubain 2mg q6 • Ketorolac 10mg q6

  16. Second PICU Day • S> no bleeding • O>BP 90/60, afebrile • Stable VS • CBC 13.7/39/11680/N50 L40 M8 B1/268K • P> transfer to regular room

  17. Meckel’sDiverticulum

  18. Meckel’s Diverticulum • remnant of the embryonic yolk sac • Embyonal stage: omphalomesenteric duct connects the yolk sac to the gut, nutrition • 5th and 7th wk AOG: duct separates from the intestine • Yolk sac + lining epith similar to stomach • Partial or complete failure of involution of the omphalomesenteric duct results in various residual structures.

  19. Frequency • Occurs in 2–3% of all infants • a 3–6 cm outpouching of the ileum along the antimesenteric border 50–75 cm from the ileocecal valve • 1st 2 years of life, 2.5yo

  20. Manifestations • Intermittent painless rectal bleeding • Stool: brick colored or currant jelly colored. • Bleeding: self-limited, contraction of the splanchnic vessels • r/o acute appendicitis • Diverticulitis can lead to perforation and peritonitis

  21. Diagnosis • Meckel radionuclide scan: IV infusion of technetium-99m pertechnetate: mucus secreting ectopic gastric mucosa : visualization of the Meckel diverticulum • sensitivity enhanced scan : 85% • specificity : 95%. • Other methods of detection: abdominal ultrasound, superior mesenteric angiography, abdominal CT scan, and exploratory laparoscopy.