1. Dr. H. Flageole Department of Surgery McMaster Children’s Hospital October 15, 2008

2. Objectives  To familiarize the resident with non- traumatic emergencies  To familiarize the resident with surgical emergencies encountered in the newborn and early childhood periods.  Identify symptoms of significant disease  Recognize life-threatening surgical conditions

3. Acute Abdomen  Often unable to get history  Importance of congenital anomalies  Make sure stomach and bladder are empty  Differential diagnosis  GI surgical and medical problems  urinary

5. ADMISSION TO SURGICAL WARD WITH ACUTE ABDOMINAL PAIN NSAP30% Acute appendicitis28% Constipation11% URTI8% UTI6.9% Gastroenteritis3.6% Pneumonia2.2% SBO (incl. Intussusception)2.2% Mesenteric adenitis (operated)2.2% Abdominal injuries1% Hepatitis1% Torsion of testis Pancreatitis< 1% OM Diabetic acidosis

6. History  Vomiting: reflex vs. obstructive  bilious or non-bilious  Abdominal pain: visceral vs. peritoneal  crampy vs. constant  GI bleed: colour, amount, signs, association with pain

7. General Management ABC Fluids and electrolytes NG tube Antibiotics Pain control

10. Pyloric Stenosis Incidence –Rare in blacks –0.5 - 2/1000 live births Age: 3 weeks - 3 months Non-bilious vomiting Olive is not easily palpable Ultrasound is very accurate

11. Pyloric Stenosis Beware of acid-base and electrolyte imbalances. Hypokalemic, hypochloremic metabolic alkalosis surgical complications Wound infection – 10% Accidental opening of GI tract

17. Pre-op management  IV fluid:  If alkalotic, when is it safe to operate and why?

19. Intussusception CLINICAL SUSPICION X-RAY U/S REDUCTION BY BARIUM / AIR ENEMA

20. What is the intussuscipiens?

22. Intussusception Age: 3 months – 3 years Crampy abdominal pain Traction of the mesentery  pallor, lethargy typically in younger infants Blood & mucous in stool (red current jelly)

23. Intussusception Crampy abdominal pain80% Vomiting (early=reflex)60-80% Rectal bleeding30-50% Palpable mass30-60% Others –Lethargy, diarrhea, fever

27. Barium enema

28. Air enema

29. Intussusception Beware of the 15% who are atypical Young infants are often just lethargic Don’t hesitate to do an ultrasound when the history is suggestive

31. In older children, suspect a lead point. What lesions could act as lead points?

32. Lead Points  Meckel’s diverticulum  Polyps  Henoch-Schonlein purpura (HSP)  Lymphoma  Intestinal duplications

33. Treatment  Success rate of enema reduction around 80%  Small risk of perforation (2.5%)  What would you do?  Laparoscopic reduction  When there is lead point, usually cannot be reduced.  Resection with primary anastomosis

35. Midgut Volvulus Secondary to MALROTATION Age: 80% under 12 months old Sudden onset of GREEN vomiting Exam and X-rays may be normal initially

36. Who knows? - Normal position of Ligament of Treitz? - Normal position of IC valve? - What we mean by base of mesentery? - Why does malrotation predispose to volvulus?

44. Who knows the steps of a Ladd’s procedure?

45. Ladd’s procedure  Reduction of volvulus  Division of Ladd’s bands  Widening of mesenteric base  Appendectomy

47. Small Bowel Obstruction

48. 5 pediatric causes

49.  Incarcerated hernia  congenital anomaly/band, internal hernia  Volvulus  Post-operative adhesions  Febrile obstruction: ruptured appendicitis

50. A small bowel obstruction in a virgin abdomen is a surgical indication

52. Acute Appendicitis Symptomatology in 691 Patients < 12 Years Pain98.7% Vomiting81.5% Urinary symptoms14% Diarrhea10%

53. Acute Appendicitis J Pediatr Surg 36:5, 2001 pp 780-783  Number of patients 454  Goal: to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography.

54. Clinical Outcomes

55. Conclusions  U/S should be reserved for patients who cannot receive a diagnosis on clinical grounds alone.  To obtain an U/S should be a surgical decision after a surgical evaluation  Greater role in post-pubertal females

56. What are the radiological criteria to make the diagnosis of acute appendicitis?

57.  Size > 6mm  Non – compressibility  Corresponds to area of maximal tenderness  Identification of a fecalith  Free fluid  Fat stranding

59. CT & Acute Appendicitis in Adults Sensitivity:  90% for CT  76% for clinical exam (p<0.0005) Specificity: 97% Bettina Siewert et al., Beth Israel Hospital Harvard Medical School 1/1997

60.  Used infrequently  Occasionally in older, obese teenagers  Concern about radiation CT & Acute Appendicitis in Children

62. Gastrointestinal Bleeding Upper GI: tarry, melena stool Lower GI: red blood, clot Injury to mucosa: mixture of blood & mucous

63. GI Bleeding Rarely life-threatening Upper GI causes: –Most: ASA, viral –Massive bleed: varices, ulcer Lower GI causes –Most: fissure, polyp, IBD, HUS etc. –Massive bleed: Meckel’s diverticulum, intestinal duplication.

65. Who knows the rule of 2’s?

66.  2% of population  2 types of mucosa (gastric and pancreatic)  2 feet from the ileocecal valve  2 types of presentation  Obstruction  Bleeding  2 inches long  2 other things I likely forgot

68. Meckel’s diverticulum  Will cause massive, painless LGI bleed to the point of requiring transfusion.  It is important to give H2 blockers for 3-5 days prior to doing a Meckel scan to increase its sensitivity.

70. Polyps Solitary or multiple Histology –Hyperplastic –Inflammatory - UC, nodular lymphoid HP –Hamartomas-Juvenile, Peutz Jeghers –Adenomatous (neoplastic) - Familial,Turcots syndromes

74. Polyps  Juvenile polyps will cause LGI bleed  usually solitary  In rectosigmoid (sometimes felt on DRE)  May protrude or auto-amputate  Endoscopic removal  Small bowel polyps will cause??

76. Foreign Body Ingestion X-ray: foreign body search soft tissues neck, CXR, AXR Most foreign bodies will pass through the GI tract uneventfully FB in the esophagus, alkaline batteries and long sharp ones must be removed.