Pediatric non-traumatic Surgical Emergencies

1. Dr. H. Flageole Department of Surgery McMaster Children’s Hospital October 15, 2008 Pediatric non-traumaticSurgical Emergencies

2. 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

3. 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

4. What is the most common cause of acute abdomen in children?

5. 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

6. 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

7. General Management • ABC • Fluids and electrolytes • NG tube • Antibiotics • Pain control

10. 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

11. Pyloric Stenosis • Beware of acid-base and electrolyte imbalances. • Hypokalemic, hypochloremic metabolic alkalosis • surgical complications • Wound infection – 10% • Accidental opening of GI tract

17. Pre-op management • IV fluid: • If alkalotic, when is it safe to operate and why?

19. Intussusception CLINICAL SUSPICION X-RAY U/S REDUCTION BY BARIUM / AIR ENEMA

20. What is the intussuscipiens? What is the intussusceptum?

22. 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)

23. Intussusception • Crampy abdominal pain 80% • Vomiting (early=reflex) 60-80% • Rectal bleeding 30-50% • Palpable mass 30-60% • Others • Lethargy, diarrhea, fever

27. Barium enema

28. Air enema

29. 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

31. In older children, suspect a lead point. What lesions could act as lead points? Intussusception

32. Lead Points • Meckel’s diverticulum • Polyps • Henoch-Schonlein purpura (HSP) • Lymphoma • Intestinal duplications

33. 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

35. Midgut Volvulus • Secondary to MALROTATION • Age: 80% under 12 months old • Sudden onset of GREEN vomiting • Exam and X-rays may be normal initially

36. 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?

44. Who knows the steps of a Ladd’s procedure?

45. Ladd’s procedure • Reduction of volvulus • Division of Ladd’s bands • Widening of mesenteric base • Appendectomy

47. Small Bowel Obstruction

48. 5 pediatric causes

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

50. A small bowel obstruction in a virgin abdomen is a surgical indication Small Bowel Obstruction