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Paediatric Surgery Notes

Medicine Notes > Paediatrics Notes

This is an extract of our Paediatric Surgery document, which we sell as part of our Paediatrics Notes collection written by the top tier of University Of Nottingham students.

The following is a more accessble plain text extract of the PDF sample above, taken from our Paediatrics Notes. Due to the challenges of extracting text from PDFs, it will have odd formatting:

A13CHH: PAEDIATRIC SURGERY PAEDIATRIC SURGERY ACUTE ABDOMEN Causes

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Of the surgical causes, appendicitis is by far the most common

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Always check testes, hernial orifices, hip joints

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Lower lobe pneumonia may cause pain referred to the abdomen

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Primary peritonitis ascites from nephrotic syndrome or liver disease

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DKA may cause severe abdominal pain

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UTI can cause acute abdo pain test urine sample for DM, infection etc

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50% of children admitted with acute abdo pain will resolve spontaneously

APPENDICITIS

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Commonest cause needing surgery

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Uncommon in <3yr olds

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Pathophysiology:

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Usually due to Faecolith obstructing the lumen of the appendix*

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612hrs: inflammatory process through full thickness of appendix wall (central colicky pain - appendicular midgut colic)

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2436hrs: gangrenous appendix + perforation (localised pain to RIF - from localised peritoneal inflammation)

Symptoms:

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Faecolith = hardening of faeces into lumps of varying size

Anorexia, vomiting (usually only a few times), abdominal pain (initially central and colicky localising to RIF)

Signs:

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Flushed face + oral fetor

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Low grade fever 37.238oC

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Abdominal pain exacerbated on movementChild lies still with knees flexed

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Persistent tenderness + guarding at McBurney's point (RIF)

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Signs & symptoms not always present, admit child if unsure - be aware of atypical presentations

1 A13CHH: PAEDIATRIC SURGERY o

Must monitor, observe & review regularly - appendicitis is a progressive condition and clinical review every few hours is key to making the correct diagnosis, avoiding delay on the one hand and unnecessary laparotomy on the other

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In Preschool Children -

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Diagnosis is more difficult, particularly early in the disease

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Faecoliths are more common and can be seen on a plain abdominal XRay

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Perforation may be rapid, as the omentum is less well developed and fails to surround the appendix, and the signs are easy to underestimate at this age

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Retrocaceal appendix

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Fewer abdominal signs + absent localised guarding

Investigations:

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NO LAB Ix/IMAGING IS USEFUL

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CLINICAL DIAGNOSIS

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Neutrophilia is not always present

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Pyuria + Bacteruria are common in appendicitis (30%) as the inflamed appendix may be adjacent to the ureter or bladder temptation to diagnose UTI avoid starting Rx unless there is dysuria

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Consider Abdominal USS if symptoms are severe - may support the clinical diagnosisThickened, noncompressible appendix with increased blood flowAssociated complications - abscess, perforation or appendix massExclude other pathology

Laparoscopy - In some centres

Management:

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Laparoscopy +/ Appendicectomy

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Straightforward in uncomplicated appendicitis; complicated appendicitis includes the presence of an appendix mass, an abscess or perforation

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If there is generalised guarding consistent with perforation, fluid resuscitation + ABx given prior to laparotomy

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If palpable mass in RIF but no signs of generalised peritonitis, it may be reasonable to elect for conservative management with IV Abx, with Appendicectomy being performed electively after several weeks

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Abscess on abdo USS operative drainage + Appendicectomy

NONSPECIFIC ABDOMINAL PAIN + MESENTERIC ADENITIS

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Nonspecific abdominal pain = abdo pain that resolves within 2448hrs

2 A13CHH: PAEDIATRIC SURGERY o

The pain is less severe than in appendicitis, and tenderness in the RIF is variable

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It is often accompanied by an URTI with cervical lymphadenopathy

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In some of these children, the abdominal signs do not resolve and an Appendicectomy is performed

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Mesenteric Adenitis

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Inflammation of Mesenteric Lymph Nodes in abdomen

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The diagnosis of mesenteric adenitis should be suspected with a history of URTI + cervical lymphadenopathy

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Presents with fever, malaise and central abdominal pain

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Diagnosis can only be confirmed if a large mesenteric lymph node is found on laparoscopy or laparotomy

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In some patients the pain may continue and the appendix is then removed as the two conditions can be extremely hard to tell apartAlthough Mesenteric Adenitis tends to remain static or improve it does NOT typically progress like appendicitis

INGUINAL HERNIAE

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Boys, Right side, 15% bilateral

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Possibly due to a failure in the descent of the inguinoscrotal descent of the testis, usually due to a patent Processus Vaginalis

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The processus vaginalis (or vaginal process) is an embryonic developmental outpouching of the peritoneum

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Failure of closure of the processus vaginalis leads to the propensity to develop a number of abnormalities. Persistent patent processus vaginalis is more common on the right than the left.

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Inguinal hernias in children are almost always indirect

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Indirect Inguinal Hernia: pass through the internal (deep) inguinal ring and, if large, out through the external (superficial) ring; deep ring = midpoint of the inguinal ligament; superficial ring = split in the external oblique aponeurosis just superior and medial to the pubic tubercle

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Direct Inguinal Hernia: push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall (Hesselbach's Triangle; medial to the inferior epigastric vessels and lateral to the rectus abdominus)

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Inguinal Canal Contents: external spermatic fascia (from external oblique), cremasteric fascia (internal oblique), internal spermatic fascia (tranversalis fascia), spermatic cord (vas deferens, obliterated processus Vaginalis, lymphatics), arteries to the vas/cremaster/testes, pampiniform plexus, genital branch of genitofemoral/sympathetic nerves, ilioinguinal nerve [female - round ligament of uterus]

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More common on the right hand side

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More common in boys (1 in 50) & preterm infants

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Presentation:

3 A13CHH: PAEDIATRIC SURGERY

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Present as intermittent swelling in groin/scrotum on crying/straining

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Lump is firm & tender

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Infant may be unwell, irritable & vomiting

Diagnosis

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Hx

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Identification of thickened spermatic cord or swelling visualised on |intraabdo pressure (gently press on abdo/ask child to cough)

Management:

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Most irreducible hernias can be |with opioid analgesia + sustained gentle compression

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Surgery = HerniotomySurgery is delayed for 2448hrs to |oedema or urgent if irreducible

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If irreducible it is emergency surgery since irreducible hernias may cause strangulation of the bowel and damage to the testes due to pressure on the gonadal vesselsInguinal skin crease incision + ligation & division of hernial sac (processus vaginalis)Day case procedure in small infantsMust be organised rapidly to prevent strangulation of bowel, damage to testis especially if <1yrs

Difference between Inguinal Hernia & Hydrocoele Inguinal hernia Hydrocoele (failure of processus vaginalis to obliterate after testicular descent through inguinal canal ? allows peritoneal fluid to track down around the testis to form a hydrocele ) Firm & tender swelling, often extends into scrotum

Asymptomatic scrotal swellings

15% are bilateral

Often bilateral

Red if incarcerated

Bluish colour sometimes

Tender or symptomless

Non-tender

Non-transluminates

Transluminate

Can't get above it

Able to get above the swelling & irreducible The majority resolve spontaneously as the processus continues

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Inguinal Hernias in Girls:

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Much less common

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Important in girls it is possible to have the ovary trapped in the hernial sack.

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Rarely testicular feminisation syndrome (androgen insensitivity) can be a cause and this should be considered.

4 A13CHH: PAEDIATRIC SURGERY INTESTINAL OBSTRUCTION TRACHEOOESOPHAGEAL FISTULA +/ ATRESIA Oesophageal Atresia

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Usually associated with TracheaOesophageal Fistula (75% of those with OA will have TOF)

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Associated with Polyhydramnios during pregnancy

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1 in 3500 live births

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Diagnosis:

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Is suspected widecalibre feeding tube passed to see if it reaches stomach identified on CXR & continuous suction applied to
|aspiration of saliva & secretions

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Presentation:

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If not diagnosed at birth, clinical presentation is with persistent salivation and drooling from the mouth after birth

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If the diagnosis is not made at this stage, the infant will cough and choke when fed, and will have cyanotic episodes

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There may be aspiration into the lungs of saliva (or milk) from the upper airways and acid secretions from the stomach

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1/2 of babies have other congenital malformation - VACTREL (Vertebral, Anorectal, Cardiac, TracheooEsophageal, Renal & Radial Limb anomalies

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Management:

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Upper oesophageal pouch should be aspirated regularly

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No need for preop ABx unless aspiration pneumonia found

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Babies on mechanical ventilation need immediate surgery to prevent gastric perforation

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SurgeryDisconnection of TOF & anastomosis of upper & lower oesophagus through R thoracotomyLong gap OA may need feeding gastrostomy & cervical oesophagostomy in neonatal period oesophageal replacement in infancyo

Complications -

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Staged procedure for high risk babies - TOF ligated OA repair later

Anastomotic leak, anastomotic stricture, gastrooesophageal & recurrent fistula

Follow up

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Respiratory morbidity is high shortly after OA/TOF repair, especially in winter months admit during respiratory infections

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Obstruction of oesophagus after OA repair is common urgent oesophagoscopy

5 A13CHH: PAEDIATRIC SURGERY Tracheooesophageal Fistula (TOF)

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Present with choking/coughing during feed, abdo distension & recurrent LRTI

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Tend not to be diagnosed till later in childhood via CXR with contrast into oesophagus & bronchoscopy

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Treatment -

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Surgical division of TOF through neck incision

ATRESIAS OF THE BOWEL Small bowel atresias

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1/3000 live births

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Aetiology ?vascular

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Pathology varies from atresia in continuity with mucosal mb to widely separated atrea with Vshaped mesenteric defect & loss of gut

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10% of atresias are multiple

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Present with bilestained vomiting & abdo distension

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AXR - multiple fluid levels, gas in duodenum & jejunum above atresia & no gas in bowel dist to atresia

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Laparotomy - endtoend anastomosis & prognosis dependent on length of remaining small bowel

Small Bowel Obstruction

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Causes Atresia or stenosis of the duodenum (1/3 have Down's)

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1/5000 live births

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1/3rd with DA have trisomy 21

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Presentation At birth with bilious vomiting

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Diagnosis - AXR: Double Bubble Sign of gas in the stomach and proximal duodenum, no gas in bowel distal to atresia

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Surgical Management - side to side duodenoduodenostomy

Atresia or stenosis of the jejunum or ileum (may be multiple)

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1/3000 live births

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Aetiology ?vascular

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Pathology varies from atresia in continuity with mucosal mb to widely separated atresia with Vshaped mesenteric defects &
loss of gut

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10% of atresias are multiple

6 A13CHH: PAEDIATRIC SURGERY

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Presentation - within 24 hours of birth; bile stained vomiting and abdominal distension

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Diagnosis - AXR - multiple fluid levels, gas in duodenum + jejunum above atresia + no gas in bowel distal to atresia

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Surgical management: Resection(s) and Anastomosis(es)

Malrotation with volvulus - severe since risk of infarction to entire midgut (or malrotation without volvulus Ladd's bands causing obstruction)

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Symptoms - include bile stained vomiting, circulatory collapse and a tender abdomen

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Diagnosis - AXR similar to duodenal atresia with a double bubble. Confirm with upper GI contrast study

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Surgical Treatment - laparotomy, second look laparotomy may be necessary if bowel viability is doubtful. Massive resection due to ischemia may result in a small bowel and long term IV feeding

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Meconium ileus syndrome (Cystic Fibrosis) occurs due to thick, puttylike meconium blocking the lower ileum, meconium plug

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1 in 2500 live births, 15% of CF sufferers

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Occasionally the obstructed bowel may perforate or result in volvulus in utero

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Present at birth with intestinal obstruction

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Rx Gastrograffin enema - hypertonic contrast draws water into bowel lumen. Laparotomy or treatment of CF if diagnoses

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Proximal obstruction presents early, distal obstruction may take some days to present

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Symptoms

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Often recognised antenatally on USS

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Bilious vomiting

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Meconium may initially be passed but it is often subsequently delayed/absent

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Signs distension become worse with more distal obstruction, tender abdo, circulatory collapse

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Investigations - abdominal Xray

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Management -

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Initially resuscitation with fluids and nasogastric suction (avoids aspiration)

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Surgery for Atresia and Stenosis

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Gastrografin contrast often dislodges meconium ileus

Large bowel obstruction

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Hirschsprungs Disease = absence of submucosal and myenteric plexuses from the rectum (may extend along the entire colon in 10% of

cases) narrow, contracted segment. Transition zone is typically the sigmoid or rectum (80%)

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Presents with absence of meconium passage within 48 hours of birth & abdominal distension.

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