dr h flageole department of surgery mcmaster children s hospital october 15 2008
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Dr. H. Flageole Department of Surgery McMaster Children’s Hospital October 15, 2008. Pediatric non-traumatic Surgical Emergencies. Objectives. To familiarize the resident with non-traumatic emergencies

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dr h flageole department of surgery mcmaster children s hospital october 15 2008
Dr. H. Flageole

Department of Surgery

McMaster Children’s Hospital

October 15, 2008

Pediatric non-traumaticSurgical Emergencies

objectives
Objectives
  • To familiarize the resident with non-traumatic emergencies
  • To familiarize the resident with surgical emergencies encountered in the newborn and early childhood periods.
  • Identify symptoms of significant disease
  • Recognize life-threatening surgical conditions
acute abdomen
Acute Abdomen
  • Often unable to get history
  • Importance of congenital anomalies
  • Make sure stomach and bladder are empty
  • Differential diagnosis
    • GI surgical and medical problems
    • urinary
admission to surgical ward with acute abdominal pain
ADMISSION TO SURGICAL WARD WITH ACUTE ABDOMINAL PAIN

NSAP 30%

Acute appendicitis 28%

Constipation 11%

URTI 8%

UTI 6.9%

Gastroenteritis 3.6%

Pneumonia 2.2%

SBO (incl. Intussusception) 2.2%

Mesenteric adenitis (operated) 2.2%

Abdominal injuries 1%

Hepatitis 1%

Torsion of testis

Pancreatitis < 1%

OM

Diabetic acidosis

history
History
  • Vomiting: reflex vs. obstructive
    • bilious or non-bilious
  • Abdominal pain: visceral vs. peritoneal
    • crampy vs. constant
  • GI bleed: colour, amount, signs, association with pain
slide7

General Management

  • ABC
  • Fluids and electrolytes
  • NG tube
  • Antibiotics
  • Pain control
slide10

Pyloric Stenosis

  • Incidence
    • Rare in blacks
    • 0.5 - 2/1000 live births
  • Age: 3 weeks - 3 months
  • Non-bilious vomiting
  • Olive is not easily palpable
  • Ultrasound is very accurate
slide11

Pyloric Stenosis

  • Beware of acid-base and electrolyte imbalances.
    • Hypokalemic, hypochloremic metabolic alkalosis
  • surgical complications
      • Wound infection – 10%
      • Accidental opening of GI tract
pre op management
Pre-op management
  • IV fluid:
  • If alkalotic, when is it safe to operate and why?
intussusception
Intussusception

CLINICAL SUSPICION

X-RAY

U/S

REDUCTION BY BARIUM / AIR ENEMA

intussusception1
Intussusception
  • Age: 3 months – 3 years
  • Crampy abdominal pain
  • Traction of the mesentery  pallor, lethargy
    • typically in younger infants
  • Blood & mucous in stool (red current jelly)
intussusception2
Intussusception
  • Crampy abdominal pain 80%
  • Vomiting (early=reflex) 60-80%
  • Rectal bleeding 30-50%
  • Palpable mass 30-60%
  • Others
    • Lethargy, diarrhea, fever
intussusception3
Intussusception
  • Beware of the 15% who are atypical
    • Young infants are often just lethargic
  • Don’t hesitate to do an ultrasound when the history is suggestive
in older children suspect a lead point what lesions could act as lead points
In older children, suspect a lead point.

What lesions could act as lead points?

Intussusception

lead points
Lead Points
  • Meckel’s diverticulum
  • Polyps
  • Henoch-Schonlein purpura (HSP)
  • Lymphoma
  • Intestinal duplications
treatment
Treatment
  • Success rate of enema reduction around 80%
  • Small risk of perforation (2.5%)
    • What would you do?
  • Laparoscopic reduction
  • When there is lead point, usually cannot be reduced.
  • Resection with primary anastomosis
slide35

Midgut Volvulus

  • Secondary to MALROTATION
  • Age: 80% under 12 months old
  • Sudden onset of GREEN vomiting
  • Exam and X-rays may be normal initially
who knows
Who knows?
  • Normal position of Ligament of Treitz?

- Normal position of IC valve?

  • What we mean by base of mesentery?
  • Why does malrotation predispose to volvulus?
ladd s procedure
Ladd’s procedure
  • Reduction of volvulus
  • Division of Ladd’s bands
  • Widening of mesenteric base
  • Appendectomy
slide49

Incarcerated hernia

  • congenital anomaly/band, internal hernia
  • Volvulus
  • Post-operative adhesions
  • Febrile obstruction: ruptured appendicitis
slide52

Acute Appendicitis

  • Symptomatology in 691 Patients < 12 Years
  • Pain 98.7%
  • Vomiting 81.5%
  • Urinary symptoms 14%
  • Diarrhea 10%
acute appendicitis j pediatr surg 36 5 2001 pp 780 783
Acute AppendicitisJ Pediatr Surg 36:5, 2001 pp 780-783
  • Number of patients 454
  • Goal: to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography.
conclusions
Conclusions
  • U/S should be reserved for patients who cannot receive a diagnosis on clinical grounds alone.
  • To obtain an U/S should be a surgical decision after a surgical evaluation
  • Greater role in post-pubertal females
slide57

Size > 6mm

  • Non – compressibility
  • Corresponds to area of maximal tenderness
  • Identification of a fecalith
      • Free fluid
      • Fat stranding
ct acute appendicitis in adults
CT & Acute Appendicitisin Adults

Sensitivity:

 90% for CT  76% for clinical exam (p<0.0005)

Specificity: 97%

Bettina Siewert et al., Beth Israel Hospital Harvard

Medical School 1/1997

ct acute appendicitis in children
CT & Acute Appendicitisin Children
  • Used infrequently
  • Occasionally in older, obese teenagers
  • Concern about radiation
gastrointestinal bleeding
Gastrointestinal Bleeding
  • Upper GI: tarry, melena stool
  • Lower GI: red blood, clot
  • Injury to mucosa: mixture of blood & mucous
slide63

GI Bleeding

  • Rarely life-threatening
  • Upper GI causes:
    • Most: ASA, viral
    • Massive bleed: varices, ulcer
  • Lower GI causes
    • Most: fissure, polyp, IBD, HUS etc.
    • Massive bleed: Meckel’s diverticulum, intestinal duplication.
slide66

2% of population

  • 2 types of mucosa (gastric and pancreatic)
  • 2 feet from the ileocecal valve
  • 2 types of presentation
    • Obstruction
    • Bleeding
  • 2 inches long
  • 2 other things I likely forgot
meckel s diverticulum
Meckel’s diverticulum
  • Will cause massive, painless LGI bleed to the point of requiring transfusion.
  • It is important to give H2 blockers for 3-5 days prior to doing a Meckel scan to increase its sensitivity.
polyps
Polyps
  • Solitary or multiple
  • Histology
    • Hyperplastic
    • Inflammatory - UC, nodular lymphoid HP
    • Hamartomas-Juvenile, Peutz Jeghers
    • Adenomatous (neoplastic) - Familial,Turcots syndromes
polyps1
Polyps
  • Juvenile polyps will cause LGI bleed
    • usually solitary
    • In rectosigmoid (sometimes felt on DRE)
    • May protrude or auto-amputate
    • Endoscopic removal
  • Small bowel polyps will cause??
slide76

Foreign Body Ingestion

  • X-ray: foreign body search
    • soft tissues neck, CXR, AXR
  • Most foreign bodies will pass through the GI tract uneventfully
  • FB in the esophagus, alkaline batteries and long sharp ones must be removed.
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