1. Pediatric Surgical Emergencies
Division of Pediatric Surgery
Patty Lange
September 2005

2. 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

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

4. 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

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

6. 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---

7. KUB

8. Inguinal Hernias in children

9. Patent Processus Vaginalis

10. Not so subtle Sometimes

11. High Ligation of Sac

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

13. 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--

14. Intussusception

15. “Currant jelly stool”

16. KUB

17. KUB
Intussusceptum

20. Contrast Enema

21. Incomplete Air Reduction

22. Perforation and Necrosis

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

24. 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

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

26. Embryology

27. Embryology

28. Volvulus

29. UGI
Duodenal-jejunal
junction

30. UGI
“Bird’s beak”

32. Volvulus and Ischemia

33. Dividing Ladd’s Bands

34. Widening the Mesentery

35. Positioning the Viscera

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

37. 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

38. Pyloric Stenosis--US

39. UGI

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

41. HPS

42. Thickened Pylorus

43. Pyloromyotomy

44. Pyloromyotomy Completed

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

46. 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!)

47. Hirschsprung’s Disease

48. KUB

49. Hirschsprung’s

50. Contrast Enema

51. Transition Zone

52. Leveling Colostomy
(+)
(-)

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

54. 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

55. KUB

56. US

57. Abdominal CT

58. Psoas sign

59. Laparoscopic Appendectomy

60. 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