Surgical Emergencies in Children Dr. Wasmi Alfadhli,MD,FRCSC Pediatric Surgery Department Ibn Sina Hospital 9/4/2012 • They aren’t just small adults • Size does matter! (so does age) – Vital signs – Fluid requirements – Etc… • How can we know or suspect abdominal pain in infants? – PERSISTANT CRYING – REFUSAL OF FEEDING – IRRITABILITY – FLEXION OF THIGHS ON THE ABDOMEN History • Personal data: • Chief complaint: • History of presenting illness: – pain? • • • • Associated symptoms? Previous episodes? Past diagnosis & treatment? Relation to food? • • • • • • Past medical history? Prenatal? Nutritional? Immunization? Developmental? Allergies? • • • • • History of trauma? Drug history? Family history? Recent travel? Social history? Physical Examination • GENERAL INSPECTION • ABDOMINAL EXAMINATION • FULL EXAMINATION FOR EXTRA ABDOMINAL CAUSES • General Inspection: – 1: level of consciousness – 2:any form of distress – 3:pain – 4:growth:weight, length and head circumfrance. – 5:nutritional status : obese thin or normal child?, signs of wasting , puffy eyes?(flat buttock, loose skin folds in the thigh and axilla) – 5:Hydration status • Vital signs: – Pulse – Blood pressure – Temperature – Respiratory rate Abdominal Examination • Inspection: – Distention: • A Generalized: • Fat, feces (constipation), flatus (malabsorption, intestinal obstruction) • Fluid( ascites) • Occasionally caused by grossly enlarged liver and or spleen or muscle hypotonia • Localized: • upper abdomen: gastric dilatation( pyloric stenosis) • Hepatomegaly , splenomegaly • Lower abdomen: distended bladder, masses • Palpation: – Superficial: • For tenderness, masses and rigidity – Deep palpation: • For tenderness ,masses, liver, spleen ,kidney ,urinary bladder – Percussion: • Ascites , over mass – Auscultation: • For peristalsis and bruit • Rectal Examination: – Indication: • • • • 1_acute abdomen 2_chronic constipation 3_rectal bleeding 4_suspected child abuse – Inspection: • Anal fissures, skin tags, fistula , fecal soiling , thread worms – Palpation: • anal tone, masses, tenderness ,look at the finger tip for blood Stain A CHILD WITH ACUTE ABDOMINAL PAIN Case 1 • 1 year Male • Blood in stool • What's next? – Complete History and Physical Examination – ABC • DDx? Neonates Infants Children Anal fissure Anal fissure Anal fissure NEC Intussusception Juvenile polyp Gastroenteritis Gastroenteritis Midgut volvulus Meckel's diverticulum UGI haemorrhage Meckel's diverticulum Intussusception Intussusception Milk allergy IBD Henoch Schonlein purpura Meckel’s Diverticulum • During the third week of fetal development, the midgut opens into the yolk sac,remaining temporarily connected by the vitelline duct • As intestinal maturation proceeds,the vitelline duct narrows. By the third month of embryogenesis, the duct disappears • Role of 2’s – 2% of population – 2:1 male:female – 2 feet from IC valve – Under 2yo commonest – 2 inch long – 2 types of mucosa Clinical Presentation • Symptoms are usually absent unless complications occur • Bleeding • Obstruction • inflammation (with or without perforation) Diagnosis • Meckel scan Treatment Intussusception Incidence • Can occur at any age • Greatest incidence in infants btw 5 and 9mths of age • More than ½ of all cases occur within the 1st year of life and only 10-25% of cases occur after age of 2yrs Pathophysiology • Defined as the telescoping of one portion of the intestine into another • The cause is often unknown • Thought to be viral in origin produces enlargement of the distal ileal lymphoid tissue (peyer’s patches) narrowing of the lumen setting up an impending obstructing ileocolic intussusception • Pathologic lead point occur in 4-8% of intussusception eg Meckel’s diverticulum, polyp, lymphoma and appendix • >80% are ileocolic, present with SBO and is difficult to reduce (25% success with Ba) Clinical manifestation • Crampy abdo pain begins acutely • Child may stiffen and pull legs up to the abdomen • Hyperextension, breath holding may be followed by vomiting • The attack often ceases as suddenly as it started • Later in the course – stools may become tinged with blood or currant jelly stools are passed Diagnostic studies ½ of cases , diagnosis is suspected on plain AXR: • Abdo mass • Abnormal distribution of gas and fecal contents • Sparse large bowel gas • Air fluid levels in bowel obstruction • U/S Treatment • Hydrostatic barium enema or pneumatic enema • If failed or contraindicated hydrostatic barium enema or pneumatic enema Case 2 • 2 days old male • Term • BW 2.6 kg • DDx – Malrotation – Atresia (duodenal,jujenal,ilial and colonic) – Hirschsprung disease – Meconuim ilius – Meconuim plug Malrotation Embryology • Primitive intestinal loops begin to rotate through an arc of 270 degrees around an axis formed by the SMA in a counter clockwise fashion • As this rotation occurs , the 4th part of the duodenum moves to the LUQ and fixes itself to the post abdo wall after rotating 270degrees • Malrotation of midgut occurs when normal rotational process and fixation of intestine fails to take place (10 wks) Clinical features • • • • • Incidence 1:500 live births Presents in neonatal period Approx 20-30% present after 1yr of age Males predominate 2:1 Assd GI anomalies found in 62% eg intestinal atresia, duodenal web, Meckels diverticulum, intussusception.. • Onset is acute, vomiting is chief symptom (bile vomitus) – Be aware of a child vomiting green • Less common symptoms: coffee ground vomiting, abdo distension, pain and bloody stools • In older child, chronic , vague abdo pain with intermittent vomiting, chronic diarrhoea, malabsorption and failure to thrive • 50% of cases have normal physical exam • Imaging: – Paucity of gas in SB – Coiled duodenum on UGI series – Cecal malposition on contrast enema Management • Management is Operative! – Urgent laparotomy essential to prevent gut infarction Atresias Atresias TEF ARM HPD HPD Case 3 • 6 months Male • Scrotal swelling • DDX of inguinal or scrotal swelling – Hernia – Hydrocele – Undescended or retractile testes – Testicular torsion – Lymphadenopathy Inguinal Hernia • Indirect in >99% of pediatric cases • The processes vaginalis is an elongated diverticulum of the peritoneum which accompanies the testicle upon its descent into the scrotum. • Hernia vs Hydrocele • Epidemiology – 1-2 inguinal hernias/100 live births • Up to 30% in prems • Most right-sided; 10% bilateral – 10% complicated by incarceration • Commonest cause of obstruction in infants • 70% of these by 1yo – 4-6:1 male:female • Clinical picture – Bulge in groin – Progresses to off-colour, firm, tender mass – Symptoms and signs of intestinal obstruction – Unlike hydrocele, can feel neck of mass at distal inguinal ring – Transillumination suggests hydrocele • Management – Manual reduction • 95% success – Surgery for all hernias • Emergent if not reducible Testicular Torsion • Could start with abd pain!! • Sudden onset of severe testicular pain followed by local swelling and firmness • On inspection, the involved testicle is “highriding” • Scrotum becomes swollen, red and tender Testicular Torsion • DDx – Epididymitis/ Orchitis – Torsion appendix testes Testicular Torsion • Diagnosis – In most instances, history and gentle examination will yield the correct diagnosis – U/S with doppler – Radioisotope scanning Testicular Torsion • Management – Immediate surgical exploration References • Principles and Practice of Pediatric Surgery, Keith T Oldham • Pediatric Surgery, 6th Edition, Jay L. Grosfeld • Greenfield's Surgery: Scientific Principles and Practice • Questions ?