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

From Atlas of Pediatric Surgery, Ashcraft, 1994 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