# Acute Abdominal Conditions — GCMD Library living collection

Updated: n/a · 10 episodes · 93 cited statements

## Episodes
### Appendicitis
- [Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis.](https://library.globalcastmd.com/article/use-and-accuracy-of-diagnostic-imaging-in-the-evaluation-of-pediatric-appendicit-16586) — article · [machine version](https://library.globalcastmd.com/article/use-and-accuracy-of-diagnostic-imaging-in-the-evaluation-of-pediatric-appendicit-16586.md)
- [Implementation of a Program for Appendicitis MRI in a Pediatric Hospital](https://library.globalcastmd.com/article/implementation-of-a-program-for-appendicitis-mri-in-a-pediatric-hospital-16568) — article · [machine version](https://library.globalcastmd.com/article/implementation-of-a-program-for-appendicitis-mri-in-a-pediatric-hospital-16568.md)
- [Update Course Rewind: Management of Appendicitis 2022](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674) — video · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674.md)
- [Update Course 2022 - UPDATES IN APPENDICITIS MANAGEMENT - Meera Kotagal, Tolu Oyetunji, Shawn St. Peter, and Whit Holcomb](https://library.globalcastmd.com/watch/update-course-2022-updates-in-appendicitis-management-meera-kotagal-tolu-oyetunj-5821) — video · [machine version](https://library.globalcastmd.com/watch/update-course-2022-updates-in-appendicitis-management-meera-kotagal-tolu-oyetunj-5821.md)

### Intussusception
- [Intussusception Guideline](https://library.globalcastmd.com/watch/intussusception-guideline-1529) — video · [machine version](https://library.globalcastmd.com/watch/intussusception-guideline-1529.md)
- [Impact of coronavirus disease 2019 on pediatric intestinal intussusception in the United States](https://library.globalcastmd.com/article/impact-of-coronavirus-disease-2019-on-pediatric-intestinal-intussusception-in-th-16576) — article · [machine version](https://library.globalcastmd.com/article/impact-of-coronavirus-disease-2019-on-pediatric-intestinal-intussusception-in-th-16576.md)

### Bowel Obstruction
- [Malrotation with Dr. Meera Kotagal](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621) — podcast · 13:25 · [machine version](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621.md)
- [Gastrografin Protocol for Adhesive Small Bowel Obstruction (SBO)](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713) — video · [machine version](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713.md)

### Mesenteric & Omental Cysts
- [Mesenteric and Omental Cysts](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531) — video · [machine version](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531.md)

### Intestinal Failure
- [Management of Pediatric Intestinal Failure](https://library.globalcastmd.com/article/management-of-pediatric-intestinal-failure-16383) — article · [machine version](https://library.globalcastmd.com/article/management-of-pediatric-intestinal-failure-16383.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=0) Introduction and scope of the intussusception guideline (Ep 5)
- [1:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=60) Indications for urgent surgery consult and initial triage (Ep 5)
- [3:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=180) Air enema protocol and observation after successful reduction (Ep 5)
- [5:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=300) Repeat enema criteria and operative intervention (Ep 5)
- [0:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=0) Introduction and Background on Gastrografin for Adhesive SBO (Ep 8)
- [1:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=60) Literature Basis and Protocol Development (Ep 8)
- [2:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=120) Patient Selection Criteria and Exclusions (Ep 8)
- [3:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=180) Initial Management and Gastrografin Administration (Ep 8)
- [4:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=240) Imaging Follow-up and Decision Points (Ep 8)
- [5:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=300) Monitoring Requirements and Outcomes (Ep 8)
- [0:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=0) Definition, Epidemiology, and Pathophysiology of Mesenteric and Omental Cysts (Ep 9)
- [3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180) Anatomic Distribution and Clinical Presentation (Ep 9)
- [6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360) Diagnostic Workup and Differential Diagnosis (Ep 9)
- [9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540) Management Strategies Based on Cyst Characteristics (Ep 9)
- [15:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=900) Surgical Considerations and Anatomic Variations (Ep 9)
- [18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080) Post-operative Complications, Follow-up, and Prognosis (Ep 9)
- [0:00](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=0) Introduction and Overview of Malrotation Epidemiology (Ep 7)
- [1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77) Embryologic Development and Anatomic Spectrum of Rotation Abnormalities (Ep 7)
- [3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229) Complications, Clinical Presentation, and Diagnostic Approach (Ep 7)
- [8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513) Surgical Management: Detorsion and Ladd Procedure (Ep 7)
- [12:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=737) Summary and Closing (Ep 7)
- [0:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=0) Introduction and Classification of Appendicitis (Ep 3)
- [7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420) Same Day Discharge for Non-Perforated Appendicitis and Irrigation Controversy (Ep 3)
- [15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900) Discharge Timing for Perforated Appendicitis (Ep 3)
- [25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500) Non-Operative Management of Appendicitis (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis. — Meera Kotagal (clinical) [Ep 7 · 1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77)
- Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant. — Meera Kotagal (clinical) [Ep 7 · 1:44](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=104)
- Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation. — Meera Kotagal (clinical) [Ep 7 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation. — Meera Kotagal (clinical) [Ep 7 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure. — Meera Kotagal (clinical) [Ep 7 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus. — Meera Kotagal (clinical) [Ep 7 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery). — Meera Kotagal (clinical) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus. — Meera Kotagal (epidemiological) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- About 70% of those who will have a midgut volvulus will present in the first year of life. — Meera Kotagal (epidemiological) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases. — Meera Kotagal (clinical) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy. — Meera Kotagal (clinical) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses. — Meera Kotagal (clinical) [Ep 7 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Midgut volvulus is considered the number one surgical emergency in pediatric surgery. — Meera Kotagal (opinion) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability. — Meera Kotagal (clinical) [Ep 7 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible. — Meera Kotagal (clinical) [Ep 7 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms. — Meera Kotagal (clinical) [Ep 7 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease. — Meera Kotagal (epidemiological) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- Laparoscopic approach may reduce the risk of postoperative bowel obstruction. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly. — Meera Kotagal (clinical) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion. — Meera Kotagal (opinion) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- Gastrografin use for adhesive small bowel obstruction began in the adult population approximately 10 years ago. — Meera Kotagal (epidemiological) [Ep 8 · 0:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=0)
- Gastrografin is both diagnostic (visible on X-rays to track bowel transit) and therapeutic (hyperosmolar agent draws water from bowel edema into lumen). — Meera Kotagal (clinical) [Ep 8 · 0:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=0)
- Gastrografin should only be used for adhesive small bowel obstructions, not in patients who have never had an operation. — Meera Kotagal (guideline) [Ep 8 · 2:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=120)
- Gastrografin is not appropriate for patients with concern for strangulation or peritonitis, who should be considered for immediate operative intervention. — Meera Kotagal (guideline) [Ep 8 · 2:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=120)
- Patients with active malignancy are excluded from the Cincinnati Children's Gastrografin protocol. — Meera Kotagal (guideline) [Ep 8 · 2:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=120)
- Imaging confirmation of small bowel obstruction is performed with two-view abdominal X-ray or CT. — Meera Kotagal (guideline) [Ep 8 · 3:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=180)
- Nasogastric decompression should be performed for at least one hour, or longer if the NG continues to drain bilious fluid. — Meera Kotagal (guideline) [Ep 8 · 3:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=180)
- Gastrografin dosing is age-based and diluted in water to a 50% solution. — Meera Kotagal (guideline) [Ep 8 · 3:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=180)
- The NG tube is clamped for 8 to 10 hours after Gastrografin administration, but can be unclamped at any time if the patient is nauseated or vomiting. — Meera Kotagal (guideline) [Ep 8 · 3:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=180)
- A portable plain film is obtained at 10 hours; if contrast is in or past the cecum, the NG tube is removed and diet can be advanced. — Meera Kotagal (guideline) [Ep 8 · 4:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=240)
- If contrast has not reached the cecum at 10 hours, another X-ray is obtained at 24 hours. — Meera Kotagal (guideline) [Ep 8 · 4:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=240)
- If contrast has not reached the cecum by 24 hours, strong consideration is given to operative exploration. — Meera Kotagal (guideline) [Ep 8 · 4:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=240)
- Serial abdominal exams every four hours are required throughout the protocol to ensure the patient has not progressed to peritonitis or developed an indication for urgent operative intervention. — Meera Kotagal (guideline) [Ep 8 · 5:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=300)
- Cincinnati Children's has had great success using Gastrografin for management of adhesive small bowel obstructions in children. — Meera Kotagal (opinion) [Ep 8 · 5:00](https://library.globalcastmd.com/watch/gastrografin-protocol-for-adhesive-small-bowel-obstruction-1713?t=300)
- About 60% of mesenteric and omental cysts are diagnosed by age 15 — Meera Kotagal (epidemiological) [Ep 9 · 0:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=0)
- The leading theory is that mesenteric and omental cysts arise from benign proliferation of lymphatics within the mesentery that do not communicate with the lymphatic drainage system — Meera Kotagal (clinical) [Ep 9 · 0:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=0)
- Mesenteric and omental cysts are true cysts with an epithelial lining, as opposed to pseudocysts which do not have epithelial lining — Meera Kotagal (clinical) [Ep 9 · 0:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=0)
- Mesenteric cysts are more common than omental cysts — Meera Kotagal (epidemiological) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- About 60% of mesenteric cysts are in the small bowel mesentery, 25% in the large bowel mesentery, and the remainder in the retroperitoneum — Meera Kotagal (epidemiological) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Small bowel mesentery cysts are more often chylous in nature, whereas large bowel and retroperitoneal cysts are more likely to be serous — Meera Kotagal (clinical) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Mesenteric cysts are more common in the ileal mesentery — Meera Kotagal (epidemiological) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- In adults, mesenteric and omental cysts can often be asymptomatic or incidentally found, but 40-60% of children present with symptoms — Meera Kotagal (epidemiological) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Symptoms of mesenteric and omental cysts include abdominal distension, vomiting, weight loss, fever, and acute abdominal pain — Meera Kotagal (clinical) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Acute abdominal pain from mesenteric cysts can be related to hemorrhage into the cyst or intestinal ischemia from torsion of the cyst within the bowel and mesentery — Meera Kotagal (clinical) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Mesenteric and omental cysts can present as acute or intermittent bowel obstruction — Meera Kotagal (clinical) [Ep 9 · 3:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=180)
- Ultrasound is the first choice for imaging in patients with suspected mesenteric or omental cysts — Meera Kotagal (guideline) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360)
- On ultrasound, mesenteric cysts appear as hypoechoic cystic masses with internal septations or small hyperechoic foci related to hemorrhage — Meera Kotagal (clinical) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360)
- Imaging should determine whether the cyst is macrocystic or microcystic because this changes the treatment approach — Meera Kotagal (clinical) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360)
- Cross-sectional imaging with CT (with PO and IV contrast) or MRI is often obtained after ultrasound to delineate the mass from bowel and evaluate fat planes and soft tissue — Meera Kotagal (clinical) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360)
- The differential diagnosis for abdominal cystic masses in children includes enteric duplication cysts, ovarian cysts, paratubal cysts, choledochal cysts, pancreatic/splenic/renal cysts, echinococcal cysts, urachal cysts, and hydronephrosis — Meera Kotagal (clinical) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=360)
- Microcystic or mixed micro/macrocystic mesenteric cysts are often treated initially with sirolimus — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Mixed lesions can be treated with sirolimus in combination with sclerotherapy — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Macrocystic mesenteric cysts are often treated initially with aspiration and sclerosis to reduce the cyst and symptoms without requiring surgical resection — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Sclerotherapy agents include 10% glucose, ethyl alcohol, or doxycycline mixed with saline — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- After sclerotherapy, at least 3 months should elapse before considering surgery to allow the inflammatory reaction to subside — Meera Kotagal (guideline) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- The goal of surgical resection should be complete excision of the cystic lesion — Meera Kotagal (guideline) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Surgical resection can be performed open or laparoscopically depending on surgeon comfort and cyst location — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Because cysts can be integrated into the mesentery and intestinal blood supply, small bowel or large bowel resection may be required — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- If complete cyst removal would require extensive bowel resection, marsupialization with sclerosis can be used to manage the cyst and reduce recurrence — Meera Kotagal (clinical) [Ep 9 · 9:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=540)
- Pedunculated mesenteric cysts are easier to resect and may not require bowel resection — Meera Kotagal (clinical) [Ep 9 · 15:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=900)
- Sessile cysts that are incorporated within the mesentery often require bowel resection at the time of cyst resection — Meera Kotagal (clinical) [Ep 9 · 15:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=900)
- Mesenteric cysts can extend into the retroperitoneum and involve the IVC or aorta, making them difficult or impossible to excise — Meera Kotagal (clinical) [Ep 9 · 15:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=900)
- Mesenteric cysts can be multicentric or complex with different lobules, and treatment and prognosis depend on the nature and location of the cyst — Meera Kotagal (clinical) [Ep 9 · 15:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=900)
- The major risk after aspiration and sclerosis is recurrence, which may require secondary surgical intervention — Meera Kotagal (clinical) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080)
- Recurrence risk is between 0-15% depending on the approach, and is higher with marsupialization — Meera Kotagal (epidemiological) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080)
- There are no standardized guidelines for follow-up frequency or whether imaging is required versus history and physical alone — Meera Kotagal (guideline) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080)
- The prognosis for children with mesenteric and omental cysts is quite good — Meera Kotagal (clinical) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080)
- Patients should be followed at routine intervals to ensure the cyst does not recur and cause additional symptoms — Meera Kotagal (guideline) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/mesenteric-and-omental-cysts-2531?t=1080)
- The guideline is for evaluation and management of patients who present to the ER with a history suggestive of intussusception. — Meera Kotagal (guideline) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=0)
- Indications for urgent surgery consult include acute abdomen, abnormal vital signs, ill-appearing patient, or other concerns from ED providers. — Meera Kotagal (guideline) [Ep 5 · 1:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=60)
- Once evaluated by a surgeon, a decision is made whether the patient needs emergent OR; if stable and not needing urgent intervention, the next step is ultrasound. — Meera Kotagal (guideline) [Ep 5 · 2:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=120)
- If ultrasound is positive for intussusception, a surgical consult is called if not previously obtained. — Meera Kotagal (guideline) [Ep 5 · 3:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=180)
- Patients with positive ultrasound undergo air enema, and surgeons must be aware of the patient prior to the enema. — Meera Kotagal (guideline) [Ep 5 · 3:30](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=210)
- In-person surgical evaluation can occur before or after the air enema if the patient is clinically stable. — Meera Kotagal (guideline) [Ep 5 · 4:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=240)
- If air enema successfully reduces the intussusception, patients are observed in the ED for four hours, then have a PO trial and can be discharged if clinically well. — Meera Kotagal (guideline) [Ep 5 · 4:30](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=270)
- If the first air enema attempt fails to reduce the intussusception, the enema can be repeated every hour for up to three times with monitoring in between, as long as the intussusceptum continues to reduce, there is no free air, and the patient remains clinically stable. — Meera Kotagal (guideline) [Ep 5 · 5:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=300)
- A fellow or attending surgeon should be notified if the patient is undergoing more than one air enema. — Meera Kotagal (guideline) [Ep 5 · 6:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=360)
- If the intussusceptum cannot be completely reduced after three air enema attempts, the patient goes to the OR for manual reduction. — Meera Kotagal (guideline) [Ep 5 · 6:30](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=390)
- This guideline may not apply to all patients. — Meera Kotagal (opinion) [Ep 5 · 7:00](https://library.globalcastmd.com/watch/intussusception-guideline-1529?t=420)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Malrotation occurs in about 1 in 200 to 500 live births. — Em Tombash summarizes what Dr. Meera Kotagal said [Ep 7 · 0:28](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=28)
- You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation. — Em Tombash summarizes what Dr. Meera Kotagal said [Ep 7 · 8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513)
- Perforation is defined as having a hole in the appendix or a fecalith in the abdomen, based on a 2008 paper that showed this classification impacted abscess rates in a clinically logical way. — Sueso Diah Quihena summarizing a resource [Ep 3 · 0:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=0)
- Gangrenous appendicitis is classified as non-perforated and patients typically fall into the group that would get sent home. — Sueso Diah Quihena summarizing a resource [Ep 3 · 0:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=0)
- The initial same-day discharge study in 2013-14 achieved 28% successful discharge rate. — Sueso Diah Quihena summarizing a resource [Ep 3 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A recent study showed 87% successful same-day discharge rate for non-perforated appendicitis, which has become the norm. — Sueso Diah Quihena summarizing a resource [Ep 3 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A 2012 randomized study comparing suction to irrigation (minimum 500 ccs, average 850 ccs) showed no difference in outcomes. — Sueso Diah Quihena summarizing a resource [Ep 3 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A retrospective study using 3 to 12 liters of irrigation in 50 cc aliquots showed 0% abscess rate in irrigated patients compared to 18.9% in perforated appendicitis population. — Sueso Diah Quihena summarizing a resource [Ep 3 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- In Cincinnati's practice using suction without irrigation, no major difference in abscess rate has been observed. — Sueso Diah Quihena summarizing a resource [Ep 3 · 7:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- Discharge criteria for perforated appendicitis include patient being afebrile, having good pain control, and tolerating diet. — Sueso Diah Quihena summarizing a resource [Ep 3 · 15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Patients typically transition from clears to solids on day one, and by day two breakfast is about the fastest discharge timing typically seen. — Sueso Diah Quihena summarizing a resource [Ep 3 · 15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Previous trials showed a 20% abscess rate that was fixed across different antibiotic regimens and irrigation protocols. — Sueso Diah Quihena summarizing a resource [Ep 3 · 15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Abscess rate dropped to about 10% after changing practice to treat patients as healthy rather than sick. — Sueso Diah Quihena summarizing a resource [Ep 3 · 15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Cincinnati implemented a protocol using QI techniques and found no change in readmission rate for abscess when discharging patients by day two post-op. — Sueso Diah Quihena summarizing a resource [Ep 3 · 15:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Eligibility criteria for non-operative management include symptoms less than 48 hours, imaging confirmation with appendiceal diameter less than 1.1 cm, no abscess/phlegmon/fecalith, and white count between 5 and 18. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- The Cota trial was a pragmatic randomized control trial on the adult side examining non-operative management. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- A patient and family choice study was conducted in the Midwest Pediatric Surgical Consortium examining non-operative management in children. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- The multicenter trial was designed as a non-inferiority trial with a non-inferiority margin set at around 20% based on surgeon consensus. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Interim analysis shows approximately 31-32% one-year failure rate for non-operative management. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Not all failures of non-operative management had appendicitis on histology when they eventually had surgery. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Non-operative management showed a non-significant three extra days of school absence compared to surgical management. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Many patients treated non-operatively have an interval appendectomy, which can be scheduled electively and may provide better quality of life than admission. — Sueso Diah Quihena summarizing a resource [Ep 3 · 25:00](https://library.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)

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