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Pediatric Emergencies

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Presentation on theme: "Pediatric Emergencies"— Presentation transcript:

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.


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