An 11-year old boy with complex needs attended the emergency department with a 48-h history of being unwell with cough, vomiting, distended abdomen and reduced responsiveness. A diagnosis of sepsis with secondary paralytic ileus was made and the patient was transferred to the Paediatric Intensive Care Unit. He was treated with intravenous fluids and broad-spectrum intravenous antibiotics and started to recover.
On day 10 of admission, the patient suffered from an episode of melaena. The abdomen was mildly distended but soft and non tender with a functioning ileostomy. . The melaena resolved, but then recurred on Day 15 of admission with the patient's haemoglobin dropping from 90 to 76. This responded initially to transfusion but over 6 hours the haemoglobin level dropped from 116 to 63 which required a further transfusion and the commencement of Tranexamic acid. The patient was taken to theatre urgently to undergo upper gastrointestinal tract endoscopy with the plan to proceed to laparoscopy if required.
At laparoscopy there was no peritoneal contamination but small bowel adhesions were identified cephalad to the ileostomy. These adhesions could not be taken down laparoscopically and so the procedure was converted to an open operation. At laparotomy, an adhesion to the anterior abdominal wall was identified with a 180° volvulus. Within this, intestinal continuity had been restored by a jejuno-jejunal fistula at the neck of the volvulus. The gastrointestinal haemorrhage had been caused by fistula erosion through a mesenteric vessel. A 10cm segment of jejunum was excised and a primary end-to-end anastomosis was performed with 4/0 vicryl sutures. Post-operatively, the patient was transferred back to the paediatric intensive care unit and made a steady recovery.
This unusual case highlights the difficulties in assessing the abdomen of a child with complex needs and multiple pathologies. These children have dysmotile and/or dysfunctional gastrointestinal tracts that are difficult to manage and can result in unusual and challenging surgical presentations. This case also emphasises that diagnostic laparoscopy is an invaluable tool in the assessment of a child with gastrointestinal bleeding where endoscopy has not provided a diagnosis.
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