Pediatric Surgical Pediatric Surgical EmergenciesEmergencies

Division of Pediatric SurgeryDivision of Pediatric Surgery

Patty LangePatty Lange

September 2005September 2005

ObjectivesObjectives

Understand what constitutes an emergencyUnderstand what constitutes an emergency Understand the basic patholophysiology of Understand the basic patholophysiology of

pediatric surgical emergenciespediatric surgical emergencies Recognize signs and symptoms of intestinal Recognize signs and symptoms of intestinal

obstruction, peritonitis, sepsisobstruction, peritonitis, sepsis Learn the basic diagnostic techniques in surgical Learn the basic diagnostic techniques in surgical

emergenciesemergencies Learn management strategies for the various Learn management strategies for the various

surgical emergenciessurgical emergencies

OutlineOutline

AppendicitisAppendicitis IntussusceptionIntussusception Pyloric StenosisPyloric Stenosis Incarcerated Inguinal herniaIncarcerated Inguinal hernia Hirschsprung’s EnterocolitisHirschsprung’s Enterocolitis Malrotation with volvulusMalrotation with volvulus

Outline ContinuedOutline Continued

What are the important points about the What are the important points about the history?history?

What are the pertinent physical findings?What are the pertinent physical findings? What is the differential diagnosis?What is the differential diagnosis? What further workup is needed?What further workup is needed? How is the problem managed?How is the problem managed? When/if to do surgery?When/if to do surgery? Postop managementPostop management

Case 1Case 1

6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension

Case 1Case 1

6mo6mo infant with vomiting, poor po intake, infant with vomiting, poor po intake, abdominal distensionabdominal distension Previous 33wk gest agePrevious 33wk gest age Non-bilious emesisNon-bilious emesis Looks illLooks ill Some respiratory problems as neonateSome respiratory problems as neonate No history of surgeries, no medsNo history of surgeries, no meds Physical exam---Physical exam---

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Inguinal Hernias in childrenInguinal Hernias in children

Patent Processus VaginalisPatent Processus Vaginalis

Not so subtle SometimesNot so subtle Sometimes

High Ligation of SacHigh Ligation of Sac

Case 2Case 2

6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension

Case 2Case 2

6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension Otherwise healthy infant, no previous feeding Otherwise healthy infant, no previous feeding

intoleranceintolerance Looks Looks wellwell, mom says , mom says intermittentintermittent fussiness fussiness Mom says pt passed Mom says pt passed reddish, thick-mucousreddish, thick-mucous

stoolstool Physical exam--Physical exam--

IntussusceptionIntussusception

““Currant jelly stool”Currant jelly stool”

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Intussusceptum

Contrast EnemaContrast Enema

Incomplete Air ReductionIncomplete Air Reduction

Perforation and NecrosisPerforation and Necrosis

Case 3Case 3

6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension

Case 3Case 3

6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension Mom says not tolerating his bottle today. Mom says not tolerating his bottle today.

Began having Began having greengreen emesis, has not had a emesis, has not had a wet diaper todaywet diaper today

Baby looks ill, not very reactive on examBaby looks ill, not very reactive on exam PE--Abd distended, tense, tenderPE--Abd distended, tense, tender

Bilious Emesis is Bilious Emesis is BADBADBilious Emesis is Malrotation Bilious Emesis is Malrotation

with Volvulus Until Proven with Volvulus Until Proven Otherwise Otherwise

EmbryologyEmbryology

EmbryologyEmbryology

VolvulusVolvulus

UGIUGI

Duodenal-jejunaljunction

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“Bird’s beak”

Volvulus and IschemiaVolvulus and Ischemia

Dividing Ladd’s BandsDividing Ladd’s Bands

Widening the MesenteryWidening the Mesentery

Positioning the VisceraPositioning the Viscera

Case 4Case 4

5wk old male infant with persistent emesis 5wk old male infant with persistent emesis for 2 weeksfor 2 weeks

Case 4Case 4

5wk old male infant with persistent emesis 5wk old male infant with persistent emesis for 2 weeksfor 2 weeks Mom says baby throws up almost every feedMom says baby throws up almost every feed

—getting worse and more forceful, emesis —getting worse and more forceful, emesis looks like the formula she feeds himlooks like the formula she feeds him

On Prevacid for reflux diagnosed 1 wk agoOn Prevacid for reflux diagnosed 1 wk ago Using rice cereal to thicken feeds but no Using rice cereal to thicken feeds but no

improvementimprovement Not wetting as many diapersNot wetting as many diapers

Pyloric Stenosis--USPyloric Stenosis--US

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ResuscitationResuscitation

Electrolytes typically showElectrolytes typically show HypokalemiaHypokalemia HypochloremiaHypochloremia Elevated bicarbonateElevated bicarbonate Indirect hyperbilirubinemia (glucuronyl Indirect hyperbilirubinemia (glucuronyl

transferase deficiency)transferase deficiency) Importance of adequate resuscitationImportance of adequate resuscitation

Anesthetic implicationsAnesthetic implications

HPSHPS

Thickened PylorusThickened Pylorus

PyloromyotomyPyloromyotomy

Pyloromyotomy CompletedPyloromyotomy Completed

Case 5Case 5

4 day old female presents to ED with 4 day old female presents to ED with lethargy, abdominal distension, emesislethargy, abdominal distension, emesis

Case 5Case 5

4 day old female presents to ED with 4 day old female presents to ED with lethargy, abdominal distension, emesislethargy, abdominal distension, emesis 37 wk gestation, Twin A37 wk gestation, Twin A Small ASD, no other medical probsSmall ASD, no other medical probs Mom says pt not making as many diapers as Mom says pt not making as many diapers as

her twin sister and not eating as muchher twin sister and not eating as much PE—abd distension, rectal exam—(make sure PE—abd distension, rectal exam—(make sure

you stand to the side!)you stand to the side!)

Hirschsprung’s DiseaseHirschsprung’s Disease

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Hirschsprung’sHirschsprung’s

Contrast EnemaContrast Enema

Transition ZoneTransition Zone

Leveling ColostomyLeveling Colostomy

(-)

(+)

Case 6Case 6

6yo male, otherwise healthy, presents to 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and pediatrician with abdominal pain and nauseanausea

Case 6Case 6

6yo male, otherwise healthy, presents to 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and pediatrician with abdominal pain and nauseanausea Dad says pt started complaining about abd Dad says pt started complaining about abd

pain yesterday after school (1pain yesterday after school (1stst day of school) day of school) Ate dinner but then woke up around midnight Ate dinner but then woke up around midnight

c/o pain againc/o pain again Vomited once this amVomited once this am Walks hunched overWalks hunched over H/O occasional constipationH/O occasional constipation

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USUS

Abdominal CTAbdominal CT

Psoas signPsoas sign

Laparoscopic AppendectomyLaparoscopic Appendectomy

SummarySummary

Bilious Emesis is BAD!! Bilious emesis is Bilious Emesis is BAD!! Bilious emesis is malrotation with volvulus until proven malrotation with volvulus until proven otherwiseotherwise

Resuscitation prior to surgery is very Resuscitation prior to surgery is very importantimportant

Clinical “Gestalt” is often the best Clinical “Gestalt” is often the best diagnostic tooldiagnostic tool