1. Pediatric Surgical Emergencies
Robert W. Letton, Jr., MD
Associate Professor, Department of Surgery
Pediatric Surgery

2. Introduction Bowel Obstruction Atresias Hirschsprung’s Malrotation
Volvulus
Intussusception
NEC
The Acute Groin
Bleeding Meckel’s
Foreign Bodies

3. Question 1?
Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis?

4. Answer Because unlike when Stan sees Wendy in Southpark©,
it usually means bowel obstruction or necrosis in our patients!

5. 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

6. 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

7. 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

8. 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

9. Atresias may be multiple

10. Jejunal Atresia

11. Imperforate Anus: Anal atresia

12. 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

13. Hirschsprung’s Disease

14. Hirschsprung’s Disease

15. 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

16. Toxic Megacolon

17. Hirschsprung’s in an 8 year old

18. Believe it or Not . . .

19. Malrotation
Normal

20. 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

21. Malrotation

22. Malrotation

23. Volvulus

24. Volvulus
Malrotation most common condition resulting in midgut volvulus
Can have volvulus with normal rotation
omphalomesenteric remnant
internal hernia
Duplication
Adhesive small bowel obstruction

25. Small Bowel Obstruction

26. Meckel’s

27. 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

28. 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

29. Intussusception

30. Intussusception

31. 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

32. Bowel Obstruction

33. 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

34. 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%

35. 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

36. NEC Abdominal Films

37. 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

38. NEC Abdomen

39. NEC Pneumoperitoneum

40. NEC Ileal Involvement

41. NEC Totalis

42. The Acute Groin

43. 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

44. Testicular Torsion

45. 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

46. Testicular Torsion

47. Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997

48. From Atlas of Pediatric Surgery, Ashcraft, 1994
Inguinal Hernia
From Atlas of Pediatric Surgery, Ashcraft, 1994

49. Incarcerated Inguinal Hernia

50. Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997

51. 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

52. 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

53. 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

54. Meckel’s

55. 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

56. 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

57. Check Valve Obstruction

58. Stop Valve Obstruction

59. 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

60. Complications Loss of airway
partial obstruction object may become complete with paralysis
Pneumothorax
vigorous positive pressure ventilation
Post-obstructive pneumonia

61. 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

62. 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

63. Diagnosis History suggests
CXR/Neck films show radiopaque coins and foreign bodies
May need contrast study to diagnoses radiolucent objects

64. Esophageal Coin

65. Esophageal “Pop Top”

66. 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

67. Complications Aspiration pneumonia Esophageal stricture
Esophageal perforation
secondary to erosion
iatrogenic
Small bowel obstruction

68. 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

69. 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!

70. Summary Bowel Obstruction Atresias Hirschsprung’s Malrotation Volvulus
Intussusception
NEC
The Acute Groin
Bleeding Meckel’s
Foreign Bodies