Paediatric GI

Question 1

A 24hr old neonate has failed to pass meconium. His abdomen is distended and he has had 3 episodes of bilious vomiting. What is your differential diagnosis?

Answer 1

• Hirschsprung’s disease
• meconium ileus
• meconium plug syndrome
• duodenal/ileal/colonic atresia
• malrotation + volvulus
• intussusception

Question 2

A 24hr old neonate has failed to pass meconium. His abdomen is distended and he has had 3 episodes of bilious vomiting. You suspect Hirschsprung’s disease.

1. Name 3 investigations you would perform to confirm the diagnosis.
2. The child is stable. How would you manage him?

Answer 2

1. Investigations:
   - AXR: air-fluid levels + colon dilation
   - contrast enema: dilated proximal bowel + transition zone + non-dilated distal bowel
   - rectal biopsy: aganglionic submucosa + presence of large ACh positive nerve trunks
2. Management:
   - initial: rectal washouts
   - definitive: anorectal pull-through procedure

Question 3

A 5yr old girl is taken to the GP by her mother, who reports her daughter is only opening her bowels once every 1-2 weeks. There are no red flags or features. The mother does report occasional overflow soiling. How would you manage this patient?

Answer 3

1. Disimpaction regimen:
   - 1st line: POLYETHYLENE GLYCOL (macrogol) + electrolytes
   - 2nd line (if not effective after 2wks): add stimulant laxative e.g. BISACODYL, SODIUM PICOSULPHATE, SENNA, DOCUSATE
2. Maintenance regimen (may be required for mths-yrs):
   - same as above