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general surgery( 三 ). Department of Pediatrics Soochow University Affiliated Children’s Hospital. Acquired surgical abnormalities. Pyloric stenosis. Pyloric stenosis Definition.

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general surgery
general surgery(三)

Department of Pediatrics

Soochow University Affiliated Children’s Hospital

slide4

Pyloric stenosis

Definition

Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical condition encountered in early infancy, occurring in 2–3 per 1,000 live births.

slide5

Pyloric stenosis

Definition

It is characterized by hypertrophy of the circular muscle, causing pyloric narrowing and elongation and producing partial or complete luminal occlusion. The incidence of the disease varies widely with geographic

location, season, and ethnic origin. Boys are affected four times more than girls.

slide7

Pyloric stenosis

Description

The appearance of the pylorus in IHPS is that of an enlarged, pale muscle mass usually measuring 2 to 2.5 cm in length and 1 to 1.5 cm in diameter.

slide8

Pyloric stenosis

Description

Histologically the mucosa and adventitia are normal. There is marked muscle hypertrophy primarily involving the circular layer, which produces partial or complete luminal occlusion

slide9

Pyloric stenosis

symptoms

  • The usual onset of symptoms occurs between 2 and 8 weeks of age with peak occurrence at 3–5 weeks of age.
  • It has been rarely reported in premature infants, especially extremely low birth weight infants, and these premature infants with IHPS present the signs and symptoms 2–4 weeks later as compared to normal term infants.
slide10

Pyloric stenosis

symptoms

  • The clinical features vary with the
  • length of symptoms. Initially the vomiting may not be frequent and forceful, but over several days it progresses to every feeding and becomes forceful nonbilious vomiting described as “projectile”.
  • The emesis consists of gastric contents, which may become blood tinged with protracted vomiting and likely related to gastritis, with “coffee-ground” appearance (17–18% of cases).
slide11

Pyloric stenosis

symptoms

  • Infants with IHPS do not appear ill or febrile in the early stages.
  • A significant delay in diagnosis leads to severe dehydration and weight loss due to inadequate fluid and calorie intake.
  • Severe starvation can exacerbate diminished glucoronyl transferase activity and jaundice associated with indirect hyperbilirubimemia as seen in 2–5% of infants with IHPS.
slide12

Pyloric stenosis

symptoms

  • It should be possible to diagnose IHPS on clinical features alone in 80–90% of infants. The important diagnostic features are visible gastric peristaltic waves in the left upper abdomen and a palpable enlarged pylorus (“olive” like mass).
slide14

Pyloric stenosis

Diagnosis

cardinal features of IHPS:

  • no bilious projectile vomiting
  • visible peristaltic waves in the left upper abdomen
  • Hypochloremic,hypokalemic metabolic alkalosis
slide15

Pyloric stenosis

Diagnosis

Ultrasonography has become the most common imaging technique for the diagnosis of IHPS under optimal circumstances, this technique can be reliable.

slide16

Pyloric stenosis

Diagnosis

The most commonly used criteria for a positive ultrasound study:

  • a pyloric muscle thickness of 4 mm or more
  • a pyloric channel length of 16 mm or more
slide19

Pyloric stenosis

Diagnosis

A barium upper gastrointestinal (UGI) examination is highly effective in making the diagnosis of IHPS and should demonstrate an elongated pyloric channel and indentation on the antral outline, which are indirect findings of pyloric muscle enlargement .

slide22

Barium meal study of IHPS. Narrowed elongated

pyloric canal giving a “string” or “double track” sign caused by

compressed invaginated folds of mucosa in the pyloric canal

slide25

Pyloric stenosis

Treatment

Pyloric stenosis can be cured with a surgical procedure called a pyloromyotomy.

intussusception definition
INTUSSUSCEPTIONDEFINITION
  • Intussusception is the most common cause of intestinal obstruction in children between 3 months and 6 years of age. It occurs when a portion of the bowel "telescopes" into itself, causing intestinal obstruction.
slide29

Intussusception occurs most commonly in infants between 15 and 19 months of age with only 10–25% of cases occurring after 2 years of age.

  • Although 90% of intussusceptions occur in children between 3 months to 3 years of age, it has also been reported in utero, in neonates, and in adults.
intussusception epidemiology
INTUSSUSCEPTION EPIDEMIOLOGY
  • Incidence 2 - 4 / 1000 live births
  • Usual age group 3 months - 3 years
  • Greatest incidence 6-12 months
  • Male predominance (1.5-2 : 1)
  • No clear hereditary association
  • No seasonal distribution
  • Frequently preceded by viral infection
  • URI, ADENOVIRUS
intussusception pathophysiology
INTUSSUSCEPTIONPATHOPHYSIOLOGY
  • Precipitating mechanism unknown
  • Obstruction of intussusceptum mesentery
  • Venous and lymphatic obstruction
  • Third spacing of fluid into bowel wall
  • Ischemic necrosis occurs in both intussusceptum and intussuscipiens
  • Pathologic bacterial translocation
slide38

When older children develop intussusception, it is usually due to what is referred to as a pathologic lead point. A lead point is a recognizable anatomic abnormality that obstructs the bowel, thus initiating the process of intussusception. Meckel\'s diverticulum and lymphoma of the intestine are two classic examples of lead points. Intestinal tumors and polyps may also act as lead points.

A pathologic lead point

intussusception clinical characteristics
INTUSSUSCEPTIONCLINICAL CHARACTERISTICS
  • The clinical presentation is more typical in infants and is characterized by episodes of abdominal colic associated with drawing up the legs and crying.
  • These episodes occur in 15–30 min intervals. In between episodes the infant is quiet.
  • Initially there may be vomiting of undigested food and streaks of blood in the stools.
intussusception clinical characteristics1
INTUSSUSCEPTIONCLINICAL CHARACTERISTICS
  • Subsequently the child becomes lethargic between episodes, develops increasing abdominal distension, bilious vomiting, and passage of red currant jelly stools.
  • Often these symptoms are preceded by an episode of diarrheal illness. Sometimes there is a history of change in diet with introduction of weaning foods.
intussusception physical evaluation
INTUSSUSCEPTIONPHYSICAL EVALUATION
  • On examination the child may be febrile and dehydrated with signs of shock in case of bowel ischemia. A curved sausage-shaped mass can be palpated anywhere in the abdomen when the infant is quiet.
  • Rectal exam is positive for blood in 60–90% of cases. Rarely a cervix-shaped mass is seen protruding beyond the anal verge.
intussusception
INTUSSUSCEPTION
  • The classic triad of incessant cry due to abdominal colic, red currant jelly stools, and a palpable abdominal mass has been reported in 20–60% of cases.
intussusception1
INTUSSUSCEPTION
  • Ultrasonography of the abdomen is often diagnostic for intussusception with a reported accuracy of up to 100% (Fig).
  • The characteristic “target sign” is described as two rings of low echogenicity with an intervening hyperechoic ring similar to a donut. The edematous walls of the intussusception appear as superimposed hyperechoic and hypoechoic layers described as the pseudo-kidney sign.
intussusception treatment
INTUSSUSCEPTIONTREATMENT
  • The initial management of children with intussusception begins with fluid resuscitation in the emergency room.
  • The correction of dehydration is crucial before attempting reduction.
  • Nasogastric decompression--argued that it is not indicated in children who do not present with vomiting.
  • Antibiotic prophylaxis including anaerobic coverage is started.
intussusception reduction
INTUSSUSCEPTIONREDUCTION
  • Nonoperative Reduction

-pneumatic

-hydrostatic reduction

intussusception pneumatic reduction
INTUSSUSCEPTIONPNEUMATIC REDUCTION
  • Pneumoenema is a cheap, safe, and effective option for the treatment of intussusception. Various studies have quoted success rates of 80–92% in reducing the Also, recurrences are less with air than barium and the morbidity is less should a perforation occur.
intussusception hydrostatic reduction
INTUSSUSCEPTIONHYDROSTATIC REDUCTION
  • Hydrostatic barium enema reduction under fluoroscopic guidance is also successful in children and is the preferred option in some centers.
  • Ultrasound-guided reduction using water (diluted with water-soluble contrast at a ratio of 9:1) has also been reported to have a success rate of 90% in the reduction of intussusception.
intussusception non operative reduction contraindications
INTUSSUSCEPTIONNON-OPERATIVE REDUCTION CONTRAINDICATIONS
  • Absolute Contraindications

PERITONEAL SIGNS

SUSPECTED PERFORATION

  • Relative Contraindications

SYMPTOMS > 24-48 HRS

RECTAL BLEEDING

POOR PROGNOSTIC INDICATORS

intussusception failure of non operative reduction
INTUSSUSCEPTIONFAILURE OF NON-OPERATIVE REDUCTION
  • Factors associated with failure

SYMPTOMS > 48 HRS

RECTAL BLEEDING

SMALL BOWEL OBSTRUCTION RADIOGRAPHICALLY

ILEOILEOCOLIC OR SMALL BOWEL TYPES

PRESENCE OF MECHANICAL LEAD POINT

AGE < 3 MONTHS

intussusception post reduction treatment
INTUSSUSCEPTIONPOST-REDUCTION TREATMENT
  • Admit patient for 24 hours
  • May attempt feeding within 12 hrs
  • Return to fluoroscopy for suspected recurrence (occurs in ~ 4%)

1.CONSIDER PATHOLOGIC LEAD POINT

2.SCHEDULE MECKEL’S SCAN, ? ABDOMINAL CT

  • May also recur up to one year
  • Need to follow as outpatient
intussusception operative reduction
INTUSSUSCEPTIONOperative Reduction
  • Operative
    • MANUAL
    • RESECTION AND REANASTAMOSIS

If the attempts at nonoperative reduction are

unsuccessful,the patient is shifted to the operating

room for a laparotomy and manual reduction of

intussusception.

slide63

Meckel\'s diverticulum

Definition

Meckel\'s diverticulum is a congenital pouch (diverticulum) approximately two inches in length and located at the lower (distal) end of the small intestine. It was named for Johann F. Meckel, a German anatomist who first described the structure.

slide65

Meckel\'s diverticulum

Description

The diverticulum is most easily described as a blind pouch that is a remnant of the omphalomesenteric duct or yolk sac that nourished the early embryo. It contains all layers of the intestine and may have ectopic tissue present from either the pancreas or stomach.

slide66

Meckel\'s diverticulum

Description

The rule of 2s is the classical description. It is located about 2 ft from the end of the small intestine, is often about 2 in in length, occurs in about 2% of the population, is twice as common in males as females, and can contain two types of ectopic tissue-stomach or pancreas. Many who have a Meckel\'s diverticulum never have trouble but those that do present in the first two decades of life and often in the first two years.

slide67

Meckel\'s diverticulum

Description

  • three major complications:
    • Inflammation or infection
    • Bleeding
    • Obstruction
slide68

Meckel\'s diverticulum

 Causes and symptoms

Meckel\'s diverticulum is not hereditary. It is a vestigial remnant of the omphalomesenteric duct, an embryonic structure that becomes the intestine. As such, there is no genetic defect or abnormality.

slide69

Meckel\'s diverticulum

 Causes and symptoms

Symptoms usually occur in children under 10 years of age. There may be bleeding from the rectum, pain and vomiting, or simply tiredness and weakness from unnoticed blood loss.

slide70

Meckel\'s diverticulum

 Causes and symptoms

It is common for a Meckel\'s diverticulum to be mistaken for the much more common disease appendicitis. If there is obstruction, the abdomen will distend and there will be cramping pain and vomiting.

slide71

Meckel\'s diverticulum

 Diagnosis

  • The situation may be so acute that surgery is needed on an emergency basis. This is often the case with bowel obstruction.
  • With heavy bleeding or severe pain, whatever the cause, surgery is required. The finer points of diagnosis can be accomplished when the abdomen is open for inspection during a surgical procedure. This situation is called an acute abdomen.
slide72

Meckel\'s diverticulum

 Diagnosis

  • If there is more time (not an emergency situation), the best way to diagnose Meckel\'s diverticulum is with a nuclear scan. A radioactive isotope injected into the bloodstream will accumulate at sites of bleeding or in stomach tissue. If a piece of stomach tissue or a pool of blood shows up in the lower intestine, Meckel\'s diverticulum is indicated.
slide74

Meckel\'s diverticulum

Treatment

A Meckel\'s diverticulum that is causing discomfort, bleeding, or obstruction must be surgically removed. This procedure is very similar to an appendectomy.

slide79

Meckel\'s diverticulum

Prognosis

The outcome after surgery is usually excellent. The source of bleeding, pain, or obstruction is removed so the symptoms also disappear. A Meckel\'s diverticulum will not return.

slide80

Appendicitis

Definition

Acute appendicitis is the most common surgical emergency in childhood. Appendicitis may present at any age, although it is uncommon in preschool children. Approximately one-third of children with acute appendicitis have perforation by the time of operation.

slide81

Appendicitis

Definition

Despite improved fluid resuscitation and better antibiotics, appendicitis in children, especially in preschool children, is still associated with significant morbidity.

slide82

Left radiograph shows a barium filled cecum and appendix. In most people the appendix buds from the posteromedial wall of the cecum just slightly below the ileocecal valve. The radiograph on the right is a mesenteric arteriogram demonstrating the rich blood supply that spreads through the mesentery to supply the bowel and appendix. Appendicular and ileocolic arteries branches supply the appendix from the inferior mesenteric artery (arrow)

slide85

McBurney’s point, two-thirds distance between

the umbilicus and right anterior superior iliac spine

slide86

Appendicitis

diagnosis

The diagnosis of acute appendicitis in childhood can sometimes be difficult. Definite diagnosis is made in only 43–72% of patients at the time of initial assessment. The rate of negative pediatric appendectomy is in the range 4–50% in various reports. The patient’s history and clinical examination are the most important tools for the diagnosis of appendicitis.

slide87

Appendicitis

diagnosis

  • Periumbilical pain is often the first symptom, followed by vomiting and fever. When the inflammation progresses, the pain
  • localizes to the right lower quadrant, and right lower quadrant tenderness develops.
  • Appendices located in the retrocaecal position may cause pain, radiating to the back.
  • Appendices in pelvic position may present with diarrhea.
slide88

Appendicitis

diagnosis

  • Clinical examination in a typical case with appendicitis reveals tenderness, guarding and rigidity in the right lower quadrant of abdomen.
  • Laboratory investigations and plain radiographs are neither sensitive nor specific in the diagnosis of appendicitis.
  • Barium enema is an unreliable test because of its high false-positive and false-negative rates.
slide89

Appendicitis

diagnosis

  • In recent years, graded compression ultrasonography of the right lower quadrant has been shown to be a useful tool in the evaluation of patients with clinical findings that are suggestive but not diagnostic of appendicitis, with a sensitivity of 80–100%, a specificity of 78–98%, and an overall accuracy of 91%.
slide90

Appendicitis

diagnosis

  • Ultrasound is portable, fast, and free of irradiationexposure, of modest incremental cost and of use indelineating gynecologic disease. However, it is oflimited use in obese adolescents and is highlyuserdependent.The only sonographic sign that is specificfor appendicitis is an enlarged, non-compressibleappendix measuring greaterthan 6 mm in maximaldiameter (Fig). The appendix may not be visible following perforation.
slide91

Ultrasonography in a 12-year-old patient with acute

appendicitis—enlarged and thickened (1.1 cm) appendix

slide92

Appendicitis

diagnosis

  • Recently, computed tomography
  • (CT) has been used as an adjunct to the diagnosisof appendicitis and appeared to have an immediateimpact, reducing negative appendectomy rates to4.1% and perforation rates to 14.7%.
  • The principaladvantages of CT are its operator independency andenhanced delineation of disease extent in perforatedappendicitis. Sensitivity, specificity and accuracy forunenhanced limited CT have approached 97%, 100%and 99%, respectively.
slide93

Appendicitis

Treatment

  • Non-perforated appendicitis
  • Treatment for appendicitis is removal of the appendix (appendectomy). Patients receive antibiotics both before and after surgery.
  • In some cases, laparoscopic surgery rather than open surgery is performed. This technique involves making a few small incisions in the belly and inserting a very small camera and surgical instruments. The pediatric surgeon then removes the appendix with the instruments.
slide95

Appendicitis

Treatment

  • Non-perforated appendicitis
  • An open appendectomy involves one larger incision in the lower right side of the abdomen. Regardless of which surgical technique is used, if the appendix has not perforated, most children are able to go home from the hospital within 24-48 hours and are able to return to school in one week.
slide96

Appendicitis

Treatment

Perforated appendicitis

If the child\'s appendix is perforated, an open surgery is often done. The child is then treated with a course of antibiotics, which is often completed at home.

slide97

Appendicitis

Treatment

  • Perforated appendicitis with abscess
  • At times, when the appendix has perforated and the infection has localized to one area, an abscess forms.
  • Treatment of the abscess includes drainage of the infection and a course of intravenous (IV) antibiotics.
slide98

Appendicitis

Treatment

  • Perforated appendicitis with abscess
  • Percutaneous (through the skin) drainage is done using ultrasound to help guide a small tube through the skin into the infected area in the belly. An appendectomy is then performed approximately 6-8 weeks after the infection has been treated.
slide101

Inflammatory Bowel Disease / IBD

Definition

Ulcerative colitis and Crohn\'s disease are called inflammatory bowel disease(s) / IBD. Ulcerative colitis and Crohn\'s disease have many similar symptoms (including diarrhea, rectal bleeding, and abdominal pain). These diseases are not contagious.

slide102

Inflammatory Bowel Disease / IBD

Definition

  • About one million Americans have IBD. Thirty thousand new cases are diagnosed every year.
  • Although the exact cause(s) of IBD is not known, these are thought to play a role in both diseases:
    • A genetic tendency
    • An environmental trigger
    • The patient\'s immune system
    • Bacteria that are normally in the intestine
slide103

Inflammatory Bowel Disease / IBD

Diagnosis

  • Diagnosing these diseases requires several tests:
    • Blood tests
    • X-rays
    • Endoscopy (looking inside the bowel with a flexible tube)
  • Ulcerative colitis can be cured by removing the colon (colectomy). There is no cure for Crohn\'s disease
slide104

Inflammatory Bowel Disease / IBD

Treatment

Medicine is tried first to help control inflammation for both ulcerative colitis and Crohn\'s disease. When inflammation is severe, steroids such as prednisone are used. In many cases, medications work to control both diseases, so surgery is not needed for a very long time

slide105

Inflammatory Bowel Disease / IBD

Treatment

  • Surgery may be recommended when medicine cannot control the symptoms or when there are other medical problems.
  • In ulcerative colitis, the disease is cured if the colon is removed.
  • Surgery for Crohn\'s disease may help relieve constant symptoms or correct problems. It is not a cure for Crohn\'s disease because the disease usually comes back.
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