Pediatric Surgical Emergencies Division of Pediatric Surgery Patty Lange September 2005

Objectives Understand what constitutes an emergency Understand the basic patholophysiology of pediatric surgical emergencies Recognize signs and symptoms of intestinal obstruction, peritonitis, sepsis Learn the basic diagnostic techniques in surgical emergencies Learn management strategies for the various surgical emergencies

Outline Appendicitis Intussusception Pyloric Stenosis Incarcerated Inguinal hernia Hirschsprung’s Enterocolitis Malrotation with volvulus

Outline Continued What are the important points about the history? What are the pertinent physical findings? What is the differential diagnosis? What further workup is needed? How is the problem managed? When/if to do surgery? Postop management

Case 1 6mo infant with vomiting, poor po intake, abdominal distension

Case 1 6mo infant with vomiting, poor po intake, abdominal distension Previous 33wk gest age Non-bilious emesis Looks ill Some respiratory problems as neonate No history of surgeries, no meds Physical exam---

KUB

Inguinal Hernias in children

Patent Processus Vaginalis

Not so subtle Sometimes

High Ligation of Sac

Case 2 6mo infant with vomiting, poor po intake, abdominal distension

Case 2 6mo infant with vomiting, poor po intake, abdominal distension Otherwise healthy infant, no previous feeding intolerance Looks well, mom says intermittent fussiness Mom says pt passed reddish, thick-mucous stool Physical exam--

Intussusception

“Currant jelly stool”

KUB

KUB Intussusceptum

Contrast Enema

Incomplete Air Reduction

Perforation and Necrosis

Case 3 6mo infant with vomiting, poor po intake, abdominal distension

Case 3 6mo infant with vomiting, poor po intake, abdominal distension Mom says not tolerating his bottle today. Began having green emesis, has not had a wet diaper today Baby looks ill, not very reactive on exam PE--Abd distended, tense, tender

Bilious Emesis is BAD Bilious Emesis is Malrotation with Volvulus Until Proven Otherwise

Embryology

Embryology

Volvulus

UGI Duodenal-jejunal junction

UGI “Bird’s beak”

Volvulus and Ischemia

Dividing Ladd’s Bands

Widening the Mesentery

Positioning the Viscera

Case 4 5wk old male infant with persistent emesis for 2 weeks

Case 4 5wk old male infant with persistent emesis for 2 weeks Mom says baby throws up almost every feed—getting worse and more forceful, emesis looks like the formula she feeds him On Prevacid for reflux diagnosed 1 wk ago Using rice cereal to thicken feeds but no improvement Not wetting as many diapers

Pyloric Stenosis--US

UGI

Resuscitation Electrolytes typically show Hypokalemia Hypochloremia Elevated bicarbonate Indirect hyperbilirubinemia (glucuronyl transferase deficiency) Importance of adequate resuscitation Anesthetic implications

HPS

Thickened Pylorus

Pyloromyotomy

Pyloromyotomy Completed

Case 5 4 day old female presents to ED with lethargy, abdominal distension, emesis

Case 5 4 day old female presents to ED with lethargy, abdominal distension, emesis 37 wk gestation, Twin A Small ASD, no other medical probs Mom says pt not making as many diapers as her twin sister and not eating as much PE—abd distension, rectal exam—(make sure you stand to the side!)

Hirschsprung’s Disease

KUB

Hirschsprung’s

Contrast Enema

Transition Zone

Leveling Colostomy (+) (-)

Case 6 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and nausea

Case 6 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and nausea Dad says pt started complaining about abd pain yesterday after school (1st day of school) Ate dinner but then woke up around midnight c/o pain again Vomited once this am Walks hunched over H/O occasional constipation

KUB

US

Abdominal CT

Psoas sign

Laparoscopic Appendectomy

Summary Bilious Emesis is BAD!! Bilious emesis is malrotation with volvulus until proven otherwise Resuscitation prior to surgery is very important Clinical “Gestalt” is often the best diagnostic tool