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    Home > Active Ingredient News > Digestive System Information > The girl had repeated abdominal pain for 6 years, but she did not see any abnormalities after many visits?

    The girl had repeated abdominal pain for 6 years, but she did not see any abnormalities after many visits?

    • Last Update: 2021-06-11
    • Source: Internet
    • Author: User
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    *The professional part involved in this article is only for medical professionals to read.
    Liu Anhuaming Youyi Village Recently, a 12-year-old girl was admitted to the hospital with "repeated abdominal pain for more than 6 years, worsening for half a year".

    Case situation: The child has repeated abdominal pain in the past 6 years, mainly in the upper abdomen and left lower abdomen, with obvious tenderness.

    No discomfort such as vomiting, fever, belching, acid reflux, etc.
    He usually had stools once a few days, dry and clumpy.

    Abdominal pain has no obvious regularity.
    There are many visits to the outside hospital.
    There is no obvious abnormality in carbon-13 breath test and abdominal color Doppler ultrasound.
    After oral probiotics, gastroprotective drugs, and laxative treatments, although there is short-term improvement, it repeats after stopping the drug.

    In this admission, the routine blood test and gastrointestinal endoscopy were perfected.
    The blood biochemical and inflammatory indicators were not high.
    The gastroscope showed chronic superficial gastritis with erosion.
    The colonoscopy showed that the endoscopy entered the sigmoid colon and saw a large amount of fecal residue, which could not be operated and observed.

    Diagnosis of this child has the following difficulties: 1.
    Long abdominal pain, accompanied by constipation, there is no abnormality in abdominal color Doppler ultrasound examination in the outside hospital, and the medical history is followed up.
    The child usually likes to eat cold drinks and sleep late.
    Combined with gastroscopy, there is Chronic gastritis, but the painful part of the child except the upper abdomen, the lower abdomen pain cannot be explained, the cause of the pain? 2.
    Physical examination after admission showed that the left lower abdomen had obvious tenderness, and the abdominal pain lasted for a long time.
    There may be abdominal masses and local encapsulated empyema? However, there are no obvious abnormalities in the abdominal color Doppler ultrasound examinations in the outer hospital.
    It is necessary to further improve the abdominal enhanced CT examination? 3.
    After admission, colonoscopy shows that the intestinal cavity is more scum, and the intestinal preparation is insufficient.
    In addition to human factors, is there any other own influences? Other factors for intestinal cleansing? After further improvement, the enhanced CT of the abdomen showed that there were more contents in the colon, the spleen area of ​​the colon was distorted, the descending colon was walking on the inside of the jejunum, there was no obstruction in the intestine, and no obvious abnormality in the appendix.

    Combined with the enhanced CT examination of the abdomen, all the above doubts are suddenly clear.
    Please consult with surgery and transfer to the surgery to further improve the gastrointestinal barium meal examination.
    After diagnosis, elective surgical treatment.

    A review of the medical history: the child had upper abdominal pain, had a habit of eating cold drinks, and sleeping late.
    After admission, a gastroscope showed that chronic superficial gastritis with erosion can still explain the cause of upper abdominal pain.

    However, the child’s left lower abdomen was painful and the pressure was obvious.
    The color Doppler ultrasound and enhanced CT of the abdomen in our hospital showed no effusion, empyema and space-occupying lesions in the abdominal cavity, and the appendix was normal.

    Before colonoscopy and abdominal CT examination, bowel cleansing was prepared, and the color of the last stool was light yellow and watery stool, but it still showed that there were more fecal residues in the intestines.
    Combined with the abdominal CT examination of the child, it can be known that due to poor rotation of the colon, Tortuousness, abnormal bowel movements, and difficulty in normal discharge of stool, can also explain the cause of long-term constipation in children.

    Congenital malrotation of the intestine is an abnormality in the anatomical position of the intestine due to obstruction or lag in the rotation of the midgut during embryonic development, leading to various surgical diseases such as intestinal obstruction or volvulus.

    The disease is one of the common diseases outside of children, often complicated by intestinal atresia, intestinal duplication, internal hernia and other malformations.

    1.
    Etiology Normal embryos develop a series of complex changes in the midgut during 6 to 12 weeks of development: At the 6th week of the embryo, the midgut grows so rapidly that the abdominal cavity cannot accommodate it and is forced to protrude from the umbilicus.

    The bowel in the umbilical cord is centered around the superior mesenteric artery and rotates in a counter-clockwise direction.

    With the development of the abdominal cavity, the protruding intestinal tube is returned to the abdominal cavity, and continues to rotate counterclockwise with the superior mesenteric artery as the center and gradually fixed to the posterior abdominal wall.

    After all intestinal rotation is completed, the small intestine starts from the Treitz ligament, obliquely from the upper left to the lower right, and ends at the ileocecal area.

    The cecum also descends to the right iliac fossa.

    During this process, if the midgut is not rotated, incompletely rotated, or rotated in the opposite direction, it can cause poor bowel rotation.

    2.
    The clinical manifestations are likely to be onset at all ages.
    Intestinal malrotation is mostly affected by newborns, accounting for about 75%, some of which are onset in childhood or adulthood, and a small number of patients are asymptomatic for life.

    1) Vomiting: Newborns often present with high intestinal obstruction at first, and sudden severe vomiting occurs intermittently.
    The vomit contains bile or small intestinal fluid, but there is still normal meconium excretion 1 to 2 days after birth, which can be associated with small intestine atresia Phase identification.

    2) Abdominal pain: The child refuses to press his abdomen because of abdominal discomfort or cramping pain, irritability and paroxysmal crying.

    Older children can tell the location and nature of the pain, with obvious local tenderness, and often take the automatic flexion position to relieve the pain.

    3) Abdominal distension: Generally, it appears later, and the degree of abdominal distension is related to the location of the intestinal obstruction.

    Duodenal obstruction is often incomplete, with bulging or gastric peristaltic waves in the upper abdomen.
    Abdominal distension is not obvious after vomiting, but it will recur with obstruction; low intestinal volvulus or colonic volvulus, torsion of bowel loops are obviously raised, and abdominal distension is more serious.

    If the intestinal volvulus is mild, the symptoms can be relieved with the position change or the own bowel movement.
    If the torsion cannot be reset, severe abdominal pain, strangulated intestinal necrosis, and toxic shock symptoms will occur in the late stage.

    3.
    Diagnosis is mainly based on clinical manifestations and imaging examinations.

    1) Abdominal X-ray film mainly manifests incomplete or complete obstruction of the digestive tract.
    The typical manifestation is duodenal obstruction, which shows the expansion of the stomach and duodenal bulb, showing "double bubble sign", but it is not the disease Specific signs.

    2) Upper gastrointestinal angiography (barium, water-soluble contrast agent): The most typical manifestation of midgut volvulus is the appearance of beak-like changes in the second and third segments of the duodenum; partial duodenal obstruction may appear as a "spiral" "pattern.

    3) barium enema examination: examination method of choice for adults and older children diagnosed with malrotation.

    mainly for ectopic right upper quadrant of the cecum is located in the upper abdomen or even left upper quadrant, ascending colon, transverse colon can The tortuous mid-upper abdomen or the entire colon is located on the left abdomen, and the ileocecal valve can be located on the right or front of the cecum.

    4) Ultrasound examination: By exploring the position and direction of the upper mesenteric blood vessels, it is helpful to diagnose intestinal malrotation.

    Normal conditions Inferior, the superior mesenteric vein is located on the right side of the superior mesenteric artery.
    If it is located in front or on the left side of the superior mesenteric artery, it may indicate intestinal malrotation.

    A meta-analysis of 2257 participants suggested that ultrasound diagnosis of malrotation compared with the reference standard The overall sensitivity with or without midgut volvulus was 94%, and the overall specificity was 100%.

    5) CT scan: The "transposition sign" and "vortex sign" of the mesenteric vessels in CT images are characteristic manifestations of the diagnosis of intestinal malrotation, which has qualitative value.

    4.
    Treatment of patients with no clinical symptoms can be followed up for observation, but with acute abdomen (obstruction symptoms, intestinal bleeding or signs of peritonitis) and surgical indications, gastrointestinal decompression should be performed to correct water, electrolyte and acid-base disorders Actively prepare for surgical treatment on the basis of improving the overall condition.

    For severe cases of intestinal necrosis and toxic shock, there is no need to wait for the shock to be completely corrected before surgery.
    Surgery should be performed while actively resisting shock.

    The purpose of surgery is to remove the obstruction as soon as possible and restore the intestinal patency.

    In the operation, the corresponding treatment method is determined according to the different detection results.

    After treatment, most children can return to normal growth and development.

    References: [1]Xiong Z,Shen Y,Morelli JN,et al.
    CT facilitates improved diagnosis of adult intestinal malrotation:a 7-year retrospective study based on 332 cases[J].
    Insights Imaging,2021,12(1) :58.
    [2]Nguyen HN,Kulkarni M,Jose J,et al.
    Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents:a systematic review and meta-analysis[J].
    Arch Dis Child,2021.
    [3 ]Han Shaoliang.
    On-duty manual for general surgery and oncological surgeons[M].
    Shanghai: Fudan University Press.
    2017:22-23.
    [4]Yu Xiangyang.
    Practical clinical general surgery[M].
    Changchun: Jilin Science and Technology Publishing Society.
    2019: 157-158.
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