Pediatric Surgical Emergencies - OU Medicine

Report
Pediatric Surgical Emergencies
Robert W. Letton, Jr., MD
Associate Professor, Department of Surgery
Pediatric Surgery
Introduction

Bowel Obstruction
 Atresias
 Hirschsprung’s
 Malrotation
 Volvulus
 Intussusception




NEC
The Acute Groin
Bleeding Meckel’s
Foreign Bodies
Question 1?
Why do Pediatric Surgeons
always make such a big deal
out of a little yellow or
green emesis?
Answer
Because unlike when Stan
sees Wendy in Southpark©,
it usually means
bowel obstruction or
necrosis in our
patients!
Bowel Obstruction
Diagnosis often age specific
 Bilious vomiting in the infant and child is a
surgical emergency until proven otherwise
 Difficult to tell when volvulus is present
 Child may look surprisingly good until it’s
too late

Atresia
Usually presents the first few days of life
 Child may feed well for a day or two with
distal atresia
 Duodenal atresia often diagnosed on
antenatal U/S
 Atresias can occur anywhere in GI tract
from pharynx to anus

Atresias
Esophageal: aspirate feeds immediately, OG
tube won’t pass
 Duodenal: bilious vomiting immediately,
“double bubble” on KUB with absence of
distal gas
 Jejunal: usually present 1st 24 hours, large
dilated proximal loop or loops

Atresias
Ileal: may take 24-48 hours before bilious
emesis
 Colonic: rare, may present with bilious
emesis after 2-3 days
 Anal: should be diagnosed at birth, often a
perineal fistula is labeled normal

Atresias may be multiple
Jejunal Atresia
Imperforate Anus: Anal atresia
Hirschsprung’s Disease
Congenital colonic aganglionosis
 Physiologic obstruction
 May present first few days to weeks of life
 Short segment disease often tolerated for
months
 Starts at anus and extends proximally a
variable distance

Hirschsprung’s Disease
Hirschsprung’s Disease
Toxic Megacolon
Severe enterocolitis
 Very rare to get with idiopathic constipation
 Usually only seen with Hirschsprung’s
Disease or Ulcerative Colitis
 NG decompression, IV fluids, IV antibiotics
 Mortality 20-30% in some studies

Toxic Megacolon
Hirschsprung’s in an 8 year old
Believe it or Not . . .
Malrotation
Normal
Malrotation
Most often presents during the first few
months of life
 Infant with acute onset of bilious emesis
 May be diagnosed on UGI for other reasons
 Malrotation is a surgical urgency due to the
possibility of volvulus
 VOLVULUS IS A SURGICAL
EMERGENCY

Malrotation
Malrotation
Volvulus
Volvulus
Malrotation most common condition
resulting in midgut volvulus
 Can have volvulus with normal rotation
 omphalomesenteric remnant
 internal hernia
 Duplication
 Adhesive small bowel obstruction

Small Bowel Obstruction
Meckel’s
Intussusception
Inversion of the bowel upon itself
secondary to a lead point
 Juvenile intussusception most often
idiopathic
 Also secondary to Meckel’s
 Presents 6 months to 2 years of age
 As early as 1 month

Intussusception
Acute painful episodes followed by periods
of lethargy
 When incarcerated progress to continuous
lethargy
 May or may not have “currant-jelly” stool
 But often stool is heme positive
 Rule out with a left lateral decubitus film

Intussusception
Intussusception
Intussusception
7% chance of recurrence after ACE
reduction
 Usually recur in 48 hours
 Operative exploration warranted on second
recurrence to R/O pathologic lead point
 Recurrence after surgery rare but possible
 Post-op intussusception can occur after any
surgery

Bowel Obstruction
Bowel Obstruction: Initial
Management
NG or OG to low wall suction (NPO!!)
 Hydrate and replace losses
 10 cc/kg of crystalloid IS NOT AN
ADEQUATE BOLUS!!
 Antibiotics if suspect perforation or necrosis
 Acute Abdominal Series
 Transfer to appropriate facility

Necrotizing Enterocolitis
Incidence: 25,000 per year; 10-70% mortality
 Most common serious GI disease of low
birth-weight infants
 Etiology is unknown
 Most common in terminal ileum and colon
 “pan-necrosis” involves >75% of gut and
occurs in 19% of patients; mortality
approaches 100%

Necrotizing Enterocolitis
Abdominal distention is most common
finding
 Feeding intolerance with bilious NG
aspirate
 Palpable bowel loops and crepitus
 Edema and erythema of abdominal wall 
peritonitis
 Rectal bleeding is common: gross and/or
occult

NEC Abdominal Films
Necrotizing Enterocolitis
Initial medical management unless evidence
of necrosis/perforation
 OG decompression
 Broad spectrum antibiotics
 NPO, TPN, fluid resuscitation
 Abdominal film surveillance
 Serial labs: CBC with platelets, ABG, CRP

NEC Abdomen
NEC Pneumoperitoneum
NEC Ileal Involvement
NEC Totalis
The Acute Groin
Testicular Torsion
Most important, not most common cause
 Peak incidence 13 to 16 years of age
 Before age 16
 60% torsion testis appendix, 30%
testicular torsion, 10% epididymitis
 Sudden testicular pain, nausea, palpation
exquisitely tender, horizontal lie,
hemiscrotum red, edematous

Testicular Torsion
Testicular Torsion
Loss of cremasteric reflex with torsion
 Torsion of appendix testis similar: point
tender at upper pole, testicle less tender
 Ultrasound and/or nuclear blood flow study
MAY be of benefit in adolescents
 smaller children difficult to perform
and/or interpret
 Do not delay surgical exploration for
studies

Testicular Torsion
Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997
Inguinal Hernia
From Atlas of Pediatric Surgery, Ashcraft, 1994
Incarcerated Inguinal Hernia
Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997
Incarcerated Hernia
If unable to reduce: urgent operative
exploration (NPO)
 If able to reduce without sedation: urgent
surgical referral with repair soon
 If extremely difficult (sedation, surgical
referral): repair next day
 Watch child for obstructive symptoms

Meckel’s
In newborns and infants present as bowel
obstruction (volvulus, intussusception)
 Bleeding most common presentation in
children
 Painless, massive, requiring transfusion
 Bleeding due to peptic ulceration at the base
of diverticulum

Meckel’s
Can diagnose with a Technetium scan
 Pretreatment with Cimetidine enhances
uptake of tracer and improves sensitivity
 Often have to repeat scan more than once
 If a 1-3 year old has two significant LGI
bleeds requiring transfusion, exploration
warranted even if scan negative
 Polyps usually don’t need transfusion

Meckel’s
Foreign Bodies
Laryngeal: Hoarseness, aphonia, dyspnea,
cyanosis
 Hot dog most common cause of fatal
aspiration
 Tracheal: asthmoid wheeze, subglottic
“thud”
 Bronchial: period of coughing and
wheezing, then asymptomatic interval

Bronchial Foreign Body
Check valve obstruction
 partial obstruction inspiration, complete
obstruction expiration
 obstructed lung expanded during
expiration
 Stop valve obstruction
 complete obstruction of
inspiratory/expiratory phase
 distal atelectasis

Check Valve Obstruction
Stop Valve Obstruction
Treatment
Removal under direct vision as soon as
possible by a “skilled” bronchoscopist
 removal with grasper or balloon catheter
 Occasionally will need thoracotomy to
“milk” FB into position for scope
 Laryngeal FB may require emergent
cricothyrotomy

Complications
Loss of airway
 partial obstruction object may become
complete with paralysis
 Pneumothorax
 vigorous positive pressure ventilation
 Post-obstructive pneumonia

Esophageal Foreign Bodies
Coins most common
 Four cardinal areas or narrowing
 below the cricopharyngeus muscle
 level of the aortic arch
 carina
 just above the diaphragm

Signs and Symptoms
Episode of coughing, choking and drooling
 Pain and dysphagia
 After an asymptomatic period get signs of
obstruction
 Pain, fever, and shock occur with
perforation

Diagnosis
History suggests
 CXR/Neck films show radiopaque coins
and foreign bodies
 May need contrast study to diagnoses
radiolucent objects

Esophageal Coin
Esophageal “Pop Top”
Treatment
Removal of foreign body under direct
vision with rigid esophagoscope
 If object has passed into stomach,
observation warranted
 Foley catheter removal possible if less than
24 to 48 hour history
 Post removal CXR

Complications
Aspiration pneumonia
 Esophageal stricture
 Esophageal perforation
 secondary to erosion
 iatrogenic
 Small bowel obstruction

Batteries
If in esophagus, treat with removal
 Most recommend removal endoscopically if
in stomach
 Difficulty arises if already in small bowel
 would require laparotomy to remove
 reports of ulceration/perforation as well
as successful passage

Question 2?
Why are Pediatric Surgeons so
interested in flatus?
Contrary to popular
belief, kids (and
adults) with
obstruction can still
have bowel
movements, but they
won’t pass gas!
Summary

Bowel Obstruction
 Atresias
 Hirschsprung’s
 Malrotation
 Volvulus
 Intussusception




NEC
The Acute Groin
Bleeding Meckel’s
Foreign Bodies

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