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


General Management

  • ABC

  • Fluids and electrolytes

  • NG tube

  • Antibiotics

  • Pain control


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


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


What is the intussuscipiens

What is the intussuscipiens?

What is the intussusceptum?


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


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




  • Incarcerated hernia

  • congenital anomaly/band, internal hernia

  • Volvulus

  • Post-operative adhesions

  • Febrile obstruction: ruptured appendicitis


A small bowel obstruction in a virgin abdomen is a surgical indication

A small bowel obstruction in a virgin abdomen is

a surgical indication

Small Bowel Obstruction


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



  • Size > 6mm acute appendicitis?

  • Non – compressibility

  • Corresponds to area of maximal tenderness

  • Identification of a fecalith

    • Free fluid

    • Fat stranding


Ct acute appendicitis in adults
CT & Acute Appendicitis acute appendicitis?in 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 Appendicitis acute appendicitis?in Children

  • Used infrequently

  • Occasionally in older, obese teenagers

  • Concern about radiation


Gastrointestinal bleeding
Gastrointestinal Bleeding acute appendicitis?

  • Upper GI: tarry, melena stool

  • Lower GI: red blood, clot

  • Injury to mucosa: mixture of blood & mucous


GI Bleeding acute appendicitis?

  • 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.


Who knows the rule of 2 s
Who knows the rule of 2’s? acute appendicitis?


  • 2 acute appendicitis?% 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 acute appendicitis?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 acute appendicitis?

  • Solitary or multiple

  • Histology

    • Hyperplastic

    • Inflammatory - UC, nodular lymphoid HP

    • Hamartomas-Juvenile, Peutz Jeghers

    • Adenomatous (neoplastic) - Familial,Turcots syndromes


Polyps1
Polyps acute appendicitis?

  • 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??


Foreign Body Ingestion acute appendicitis?

  • 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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