Transcript Pediatric Surgical Emergencies - OU Medicine
Pediatric Surgical Emergencies
Robert W. Letton, Jr., MD Associate Professor, Department of Surgery Pediatric Surgery
Introduction
Bowel Obstruction Atresias Hirschsprung’s Malrotation Volvulus Intussusception NEC The Acute Groin Bleeding Meckel’s Foreign Bodies
Question 1?
Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis?
Answer Because unlike when Stan sees Wendy in Southpark © , it usually means bowel obstruction or necrosis in our patients!
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
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
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 1 st 24 hours, large dilated proximal loop or loops
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
Atresias may be multiple
Jejunal Atresia
Imperforate Anus: Anal atresia
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
Hirschsprung’s Disease
Hirschsprung’s Disease
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
Toxic Megacolon
Hirschsprung’s in an 8 year old
Believe it or Not . . .
Malrotation
Normal
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
Malrotation
Malrotation
Volvulus
Volvulus
Malrotation most common condition resulting in midgut volvulus Can have volvulus with normal rotation omphalomesenteric remnant internal hernia Duplication Adhesive small bowel obstruction
Small Bowel Obstruction
Meckel’s
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
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
Intussusception
Intussusception
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
Bowel Obstruction
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
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%
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
NEC Abdominal Films
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
NEC Abdomen
NEC Pneumoperitoneum
NEC Ileal Involvement
NEC Totalis
The Acute Groin
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
Testicular Torsion
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
Testicular Torsion
Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997
Inguinal Hernia
From Atlas of Pediatric Surgery, Ashcraft, 1994
Incarcerated Inguinal Hernia
Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997
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
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
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
Meckel’s
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
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
Check Valve Obstruction
Stop Valve Obstruction
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
Complications
Loss of airway partial obstruction object may become complete with paralysis Pneumothorax vigorous positive pressure ventilation Post-obstructive pneumonia
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
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
Diagnosis
History suggests CXR/Neck films show radiopaque coins and foreign bodies May need contrast study to diagnoses radiolucent objects
Esophageal Coin
Esophageal “Pop Top”
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
Complications
Aspiration pneumonia Esophageal stricture Esophageal perforation secondary to erosion iatrogenic Small bowel obstruction
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
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!
Summary
Bowel Obstruction Atresias Hirschsprung’s Malrotation Volvulus Intussusception NEC The Acute Groin Bleeding Meckel’s Foreign Bodies