Dr. H. FlageoleDepartment of SurgeryMcMaster Children’s HospitalOctober 15, 2008

Objectives

To familiarize the resident with non-traumatic emergencies

To familiarize the resident with surgical emergencies encountered in the newborn and early childhood periods.

Identify symptoms of significant disease

Recognize life-threatening surgical conditions

Acute Abdomen

Often unable to get history Importance of congenital anomalies Make sure stomach and bladder are

empty Differential diagnosis

GI surgical and medical problems urinary

ADMISSION TO SURGICAL WARD WITH ACUTE ABDOMINAL PAIN

NSAP 30%Acute appendicitis 28%Constipation 11%URTI 8%UTI 6.9%Gastroenteritis 3.6%Pneumonia 2.2%SBO (incl. Intussusception) 2.2%Mesenteric adenitis (operated) 2.2%Abdominal injuries 1%Hepatitis 1%Torsion of testisPancreatitis < 1%OMDiabetic acidosis

History

Vomiting: reflex vs. obstructive bilious or non-bilious

Abdominal pain: visceral vs. peritoneal crampy vs. constant

GI bleed: colour, amount, signs, association with pain

General Management

• ABC

• Fluids and electrolytes

• NG tube

• Antibiotics

• Pain control

Pyloric Stenosis• Incidence

– Rare in blacks

– 0.5 - 2/1000 live births

• Age: 3 weeks - 3 months

• Non-bilious vomiting

• Olive is not easily palpable

• Ultrasound is very accurate

Pyloric Stenosis

• Beware of acid-base and electrolyte imbalances.

•Hypokalemic, hypochloremic metabolic alkalosis

• surgical complications

•Wound infection – 10%

•Accidental opening of GI tract

Pre-op management

IV fluid:

If alkalotic, when is it safe to operate and why?

Intussusception

CLINICAL SUSPICION

X-RAY

U/S

REDUCTION BY BARIUM / AIR ENEMA

What is the intussuscipiens?

Intussusception

• Age: 3 months – 3 years

• Crampy abdominal pain

• Traction of the mesentery pallor, lethargy

•typically in younger infants

• Blood & mucous in stool (red current jelly)

Intussusception

• Crampy abdominal pain 80%

• Vomiting (early=reflex) 60-80%

• Rectal bleeding 30-50%

• Palpable mass 30-60%

• Others

– Lethargy, diarrhea, fever

Barium enema

Air enema

Intussusception

• Beware of the 15% who are atypical

• Young infants are often just lethargic

• Don’t hesitate to do an ultrasound when the history is suggestive

In older children, suspect a lead point.

What lesions could act as lead points?

Lead Points

Meckel’s diverticulum Polyps Henoch-Schonlein purpura (HSP) Lymphoma Intestinal duplications

Treatment

Success rate of enema reduction around 80%

Small risk of perforation (2.5%) What would you do?

Laparoscopic reduction When there is lead point, usually

cannot be reduced. Resection with primary anastomosis

Midgut Volvulus

• Secondary to MALROTATION

• Age: 80% under 12 months old

• Sudden onset of GREEN vomiting

• Exam and X-rays may be normal initially

Who knows?

- Normal position of Ligament of Treitz?- Normal position of IC valve?- What we mean by base of mesentery?- Why does malrotation predispose to

volvulus?

Who knows the steps of a Ladd’s procedure?

Ladd’s procedure

Reduction of volvulus Division of Ladd’s bands Widening of mesenteric base Appendectomy

Small Bowel Obstruction

5 pediatric causes

Incarcerated hernia

congenital anomaly/band, internal hernia

Volvulus

Post-operative adhesions

Febrile obstruction: ruptured appendicitis

A small bowel obstruction in a virgin abdomen is a surgical indication

Acute Appendicitis

Symptomatology in 691 Patients < 12 Years

• Pain 98.7%

• Vomiting 81.5%

• Urinary symptoms 14%

• Diarrhea 10%

Acute AppendicitisJ Pediatr Surg 36:5, 2001 pp 780-783

Number of patients 454

Goal: to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography.

Clinical Outcomes

Outcome CG (n=263) SG (n=191) P valuePre-opobservation(%)

4.2 19.4 <0.001

ER to OR (hr) 4.93 8.04 <0.001% Negativeappendectomy

5.7 13.1 0.006

% complicatedappendicitis

37.3 35.1 NS

% post-opabscess

1.2 4.4 0.038

LOS 2.35 2.82 NS

Conclusions

U/S should be reserved for patients who cannot receive a diagnosis on clinical grounds alone.

To obtain an U/S should be a surgical decision after a surgical evaluation

Greater role in post-pubertal females

What are the radiological criteria to make the diagnosis of acute appendicitis?

Size > 6mm Non – compressibility Corresponds to area of maximal

tenderness Identification of a fecalith

Free fluid Fat stranding

CT & Acute Appendicitisin Adults

Sensitivity: 90% for CT 76% for clinical exam (p<0.0005)

Specificity: 97%

Bettina Siewert et al., Beth Israel Hospital Harvard

Medical School 1/1997

Used infrequently Occasionally in older, obese

teenagers Concern about radiation

CT & Acute Appendicitisin Children

Gastrointestinal Bleeding

• Upper GI: tarry, melena stool

• Lower GI: red blood, clot

• Injury to mucosa: mixture of blood & mucous

GI Bleeding

• Rarely life-threatening

• Upper GI causes:

– Most: ASA, viral

– Massive bleed: varices, ulcer

• Lower GI causes

– Most: fissure, polyp, IBD, HUS etc.

– Massive bleed: Meckel’s diverticulum, intestinal duplication.

Who knows the rule of 2’s?

2% of population 2 types of mucosa (gastric and

pancreatic) 2 feet from the ileocecal valve 2 types of presentation

Obstruction Bleeding

2 inches long 2 other things I likely forgot

Meckel’s diverticulum

Will cause massive, painless LGI bleed to the point of requiring transfusion.

It is important to give H2 blockers for 3-5 days prior to doing a Meckel scan to increase its sensitivity.

Polyps

• Solitary or multiple

• Histology

– Hyperplastic

– Inflammatory - UC, nodular lymphoid HP

– Hamartomas-Juvenile, Peutz Jeghers

– Adenomatous (neoplastic) - Familial,Turcots syndromes

Polyps

Juvenile polyps will cause LGI bleed usually solitary In rectosigmoid (sometimes felt on DRE) May protrude or auto-amputate Endoscopic removal

Small bowel polyps will cause??

Foreign Body Ingestion

• X-ray: foreign body search

•soft tissues neck, CXR, AXR

• Most foreign bodies will pass through the GI tract uneventfully

• FB in the esophagus, alkaline batteries and long sharp ones must be removed.