1. Pediatric Emergencies
Dr.Mohammad Saquib Mallick,FRCS
Consultant Pediatric Surgeon.

2. ACUTE ABDOMEN IN CHILDREN
Surgical Causes:
Acute appendicitis 30%
Intussusception
Meckel’s diverticulitis

3. ACUTE ABDOMEN IN CHILDREN cont..
Twisted ovarian cyst
Primary peritonitis
Malrotation of midgut
Acute Cholecystitis (rare)
Acute pancreatitis (rare)

4. ACUTE ABDOMEN IN CHILDREN cont..
Medical Causes:
Acute Non-specific abdominal pain (NSAP) 30-50%
Gastroenteritis
Constipation
Genito-urinary infection
Mesenteric adenitis

5. ACUTE ABDOMEN IN CHILDREN cont..
Pelvic inflammatory disease
Pneumonia
Measles
Sickle cell crisis
Henoch-Schönlein purpura

6. Intussusception
Pathology
Diagnosis
Management

7. Pathology Incidence: 1.5-4/1000 live births Sex: male predominance
Peak Age: months
Pathogenesis:
* invagination of intestine
* mesentery with it
* venous obs - arterial obs

8. Pathology cont.. Site: commonly - ileo-colic
less commonly - ileo-ileal
colo-colic
Aetiology: Idiopathic 90%
Adenovirus or Rotavirus
(Marked lymphoid tissue in ileum may act as leading point)
It may be associated with upper respiratory tract infection or gastroenteritis

9. Pathology cont.. Lead points:(2-10%) e.g. Meckel’s diverticulum Polyps
Intestinal duplication
Lymphomas
Henoch’s purpura
Haemangiomas

10. Diagnosis History Pain - colic every 10-15 minutes healthy infant
screaming suddenly
pulls the legs up
Stool red mucoid, bleeding PR
Vomiting - bilious
History of viral gastroenteritis or URTI

11. Diagnosis cont.. Examination
Vital sign - stable initially
dehydration, tachycardia,
temperature,
Abdomen - sausage shaped mass
bowel sounds increased
PR blood stained stool
(red current jelly)

12. Diagnosis cont.. Investigations
AXR supine and erect
USG -target lesion
- pseudo kidney sign

13. Intussusceptions
Contrast enema
coiled spring sign

14. Management Nasogastric tube Intravenous fluid therapy Antibiotics -
Blood Work-up CBC
-electrolytes
- cross-matching

15. Management cont.. Child - stable and no peritonitis
treatment - hydrostatic reduction with barium/air enema
Child - shock or peritonitis or perforation
treatment - laparotomy

16. Intussusceptions

17. Management cont.. Post operative: 8-12 % recurrence rate
Discharge - hydrostatic 1 day
laparotomy 4-7 days
Reduction of recurrence
hydrostatic / laparotomy

18. Other causes of acute abdomen in children
Intestinal obstructions
Malrotation
obstructed Inguinal hernia
Adhesions (post operative)
Meckel’s diverticulitis
Same as acute appendicit
***Cautions***
Bilious vomiting

19. Malrotation & Midgut volvulus
Most common symptom of malrotation with volvulus is Vomiting.(95%)
Abdominal distention follows with bloody diarrhea (28%)
Children with volvulus appear severely ill
Dehydration, lethargic, Peritonitis, shock

20. Malrotation & Midgut volvulus

21. Malrotation & Midgut volvulus
Investigation:
Urgent Upper GI contrast Study.
Corkscrew sign

22. Malrotation & Midgut volvulus

23. Malrotation & Midgut volvulus
Management:
Urgent Laparotomy after Resuscitation
Ladd’s procedure if bowels are alive.

24. Obstructed Inguinal Hernia
A 6 month old boy presented to your clinic with irritability, crying, vomiting, and painful swelling in right inguinal area.
On examination:
4 by 3 cm tender, nonreducible inguinal swelling, both testes are in scrotum.No other abnormalities detected.

25. Incarcerated (irreducible) inguinal hernia Management:
DIAGNOSIS ?
Incarcerated (irreducible) inguinal hernia
Management:
Sedation and analgesia
Reduction
Admission and Herniotomy after24 to 48 hours

26. Acute appendicitis Pathology Diagnosis Management Differences
Difficult and delayed
Management
Differences
high rate perforation
difficult to examine
reduced immunity
scanty omentum

27. Appendectomy open or Laparoscopy

28. Meckel’s diverticulitis

29. Twisted Ovarian cyst

30. Twisted Ovarian cyst

31. Summary- Acute abdomen in children
Acute appendicitis is an important surgical disease in children , 1 : 5 appendix will rupture prior to operation and cause serious illness
All children with acute abdomen should have urine test
Resuscitation of sick child must be done prior to operation
Diagnosis is mainly clinical however, Investigations ( US, x-rays) may be helpful

32. III: Acute Scrotum Introduction: Causes:
Acutely painful or swollen scrotum
A few real pediatric surgical emergency
Causes:
Testicular Torsion
Torsion of appendage
Epididymo-orchitis
Idiopathic scrotal edema
Other conditions e.g. incarcerated hernia, acute hydrocele, HSP, truma

33. III: Acute Scrotum Testicular Torsion: Symtoms: Signs:
Incidence: 1:4000
Common in peripubertal and perinatal
Symtoms:
Initially, it may be lower abdominal pain and vomiting
Later localized to one side of scrotum
Swollen, red scrotum
Signs:
Tender
Cremasteric reflux absent
Lies higher than contalateral tesis
Horizantal in position

34. Testicular Torsion Investigations: Management: Colour Doppler US
Radionuclide Scan
Management:
Timing is critical 4-6 hrs
Exploration if any doubt
Untwist anticlockwise “Putting the clock back” if it viable
Fix the other side
If more than 10 hrs, it is likely to be non-vialable, needs excision

35. Testicular Torsion
Extra-vaginal,
neonatal
intra-vaginal,
adolescent

36. Torsion of appendage Introduction Presentation Colour Doppler scan
Embryological remnants of the mesonephric and mullerian duct system occur as tiny ( 2-10mm long) appendages of testis ( hydatid of Morgagani), epididymis and paradidymis
Peak age yrs
Presentation
pain – more gradual onset
Blue spot in the scrotum
Swollen, red hemiscrotum
Somtimes difficult to distinguish between two conditions
Colour Doppler scan
Management: Conservative or operative if torsion cannot exclude

37. Idiopathic scrotal edema
Introduction
Cause?
Peak age 4-5 yrs
Presentation
Swollen, red hemiscrotum or bilateral
Pain minimum
Management: Conservative, self limiting within 1-2 days

38. II: Inguino-scrotal swellings
Inguinal hernia
Hydrocele
Undescended testes
Acute scrotum

39. II: Inguino-scrotal swellings
Inguinal hernia
1-5% boys
9:1 male/female
99% indirect
More in premature (up to 35%)
More in right side
Congenital in origin
Inguinal hernia? or
Hydrocele?

40. Inguinal hernia Clinical History Examination
Intermittent groin swelling
Asymptomatic until incarcerated
In girls, lump in upper part of labia mojora
Examination
Examine the testes
Cough impulse
Reducibility

41. Inguinal hernia and Hydrocele

42. Inguinal hernia Management: Herniotony Incarcerated hernia
Sedation and analgesia
Reduction
Herniotomy as soon as possible
Age is not contraindicated for operation

43. Hydrocele Clinical History Examination Management Scrotal swelling
Asymptomatic
1% over 1 years of age
Examination
Get above the swelling
Not Reducible
transilluminates
Management
Below Age 2 years surgery not advised
Ligation of PPV

44. Undescended testes Definitions: Incidence: Palpable 80%
True undescended testes
Ectopic
Retractile
Incidence:
At birth 3-4%
At one year 1%
Pre-term 30%
Nonpalpable 20%

45. Undescended testes Diagnosis: Parents/Doctors Clinical features
Empty scrotum
Palpable or not
Milk it down to scrotum
Ultrasound ?
Laparoscopy
Diagnostic
Therapeutic

46. Undescended testes Indication: Treatment: at 1 yr Abnormal fertility
Testicular tumour
Cosmetic/social
Trauma/torsion
Treatment: at 1 yr
Single stage
Orchiodopexy
Two stages:
laparoscopic

47. Abdominal wall defect
Omphalocele
Gastroschisis
Umbilical hernia

48. Abdominal wall defect Omphalocele:
A birth defect in which part of the intestine, covered only by a thin transparent membrane, protrudes outside the abdomen at the umbilicus.

49. Abdominal wall defect Omphalocele
occurs due to a failure during embryonic development for a section of the intestines (the midgut) to return from outside the abdomen and reenter the abdomen as it should.

50. Abdominal wall defect
It may be associted with other congenital abnormalities.
An omphalocele must be repaired with surgery.

51. Abdominal wall defect Gastroschisis:
A birth defect in which there is a separation in the abdominal wall. Through this opening protrudes part of the intestines which are not covered by peritoneum.

52. Abdominal wall defect Gastroschisis
The opening in the abdominal wall in gastroschisis is never at the site of the umbilicus. Rather, the umbilicus is characteristically to the left of the gastroschisis and is separated from it by a bridge of skin.

53. Abdominal wall defect
Omphalocele and gastroschisis together make up most of the major defects of the abdominal wall.
Omphalocele is more common and affects about 1 in 5,000 newborn babies.
Gastroschisis occurs in about 1 in 11,000 babies

54. Abdominal wall defect Gastroschisis
The treatment of gastroschisis is to carefully wrap it in pads soaked in saline (salt solution) so the herniated intestines do not dry out.

55. Abdominal wall defect
Nasogastric tube to remove air and decompress the intestines,
Surgically repair the gastroschisis by returning the herniated intestines to the abdomen and then closing the abdominal wall.