Nuggets in Paediatric Surgery · Bilious vomiting 2 Infant •malrotation •obstructed hernia...

Practical Paediatrics

Paediatric Surgery

JI Curry

Practical Paediatrics, June 2018

Objectives

• To review common paediatric surgical

emergencies

• Gain understanding of basic pathology

• Understand first/emergency treatment prior

to transfer


Paediatric surgery

• Different diagnoses from adult surgery

• Diagnoses can present differently in

different age groups

• Normal physiology and response to disease

vary greatly across age ranges


Take home message

• Bile stained vomiting is a “surgical

emergency” until proven otherwise


What colour is bile?


Prophylaxis !


Infant with vomiting

consider obstruction/surgical causes

yes

consider mainly medical causes

except pyloric stenosis

no

is it bilious?


Pyloric stenosis

• Consider in well hungry infant

• Test feed positive

• USS


Pyloric Stenosis

• Typical biochemistry

• NGT to drain stomach. IVI

• Transfer when surgical bed available


Bilious vomiting

Newborn

• NEC

• Hirschsprung’s disease

• ARA

• Meconium ileus

• Duodenal/jejuno-ileal atresia


Bilious vomiting 2

Infant

• malrotation

• obstructed hernia

• intussusception


Bilious vomiting 3

What should you do?

Discuss/refer


Malrotation

Surgical emergency

• bilious vomiting

• scaphoid abdomen

• beware distended stomach and absence of distal gas on AXR

• UGI diagnostic

• Urgent surgical referral


Inguinal hernias

• Lump in groin

• Parents point to external inguinal ring


Hernias

Differential diagnoses

• UDT

• Hydrocoele

• Hydrocoele of the cord

• Hernias in females contain the ovary

– still a surgical emergency if acute


Hernias - acute

• Needs urgent attention

– damage to testicle more common than to gut

• ivi, ngt

• analgesia

• reduction by experienced practitioner

• referral to paediatric surgeon


Hernias do’s and don’ts

DO NOT

• Hope it will get better

• put in elevation

• apply ice

• attempt reduction if you don’t know how to do it

DO

• Send them on a trip in an ambulance!


Intussusception

• Think of the diagnosis.

• USS (+’ve in 95%)


Intussusception

• Fluid requirements persist until reduction

• NG tube to decompress

• Give antibiotics


Intussusception - tips

• Empty RIF more reliable than “sausage

mass” (Dance’s sign)

• “red current jelly stool” present in about

25%

• Colicky abdo pain and “drawing up legs”not specific to intussusception

• Often “white as a sheet” between colics


Bilious vomiting 3

Child

• appendicitis

• obstructed hernia


Appendicitis

• Varies with age

• >5 more typical presentation

– NB 5 to 10% negative appendicectomy rate

• 2-5

– often delayed diagnosis

– mimics D & V type illness

• under 2

– perforated with generalised peritonitis


Why didn’t the other doctors

know it was appendicitis?


Appendicitis - tips

• Mainly clinical diagnosis

– can they hop on right leg?

• bloods and x-rays of little early use

• look for other causes esp. ENT

• BEWARE

– child with very high temp

– child who hasn’t vomited

– teenage females


Appendicitis is NOT a surgical

emergency


“We just got there in time”


• Study from Royal London

• Historical comparison

• Delayed surgery until 2 doses of IV

antibiotics given

• Significant improvement in post-operative

complications– McCartan et al, increase in hospital stay NOT associated with

perforation or increased morbidity)


Why

• ? Iv antibiotics

• ? Adequate resuscitation

• ? Seen by senior member of staff

• ? Operated by (or with) senior member of staff


• Ingraham et all (Arch Surg, 2010)

• Nearly 33,000 patients

• No difference in 30 day outcomes when

surgery delayed for 12 hours


Responsibility

• Ensure children are assessed by experienced member of staff

• Ensure adequate resuscitation and other urgent treatment

• Seriously question all out of hours operating on children when a consultant is not present


Abdominal pain -

points to consider• If > than 1 month has <5% chance of being

surgical

• 50% of children admitted with abdo pain will have no definitive cause found

• Beware labels if you don’t know

• Tests frequently unhelpful


Abdominal pain

• If in doubt admit

• Give analgesia if child in pain

• Actively observe

• If symptoms persist then FBC and CRP +/-

abdo x-ray

• USS in teenage girls

• Rectal exam usually not useful


Analgesia

• For children being assessed for onset of acute abdominal

pain………………

• Yes please doctor!

– Kokki et al, Arch Pediatr Adolesc Med. 2005

– Bailey et al, Ann Emerg Med. 2007


Abdominal pain

• Acute cholecystitis

• Acute pancreatitis (don’t forget the lipase)

• Acute diverticulitis (meckels)


Please

Please

Please


Mesenteric adenitis


Mesenteric adenitis

Non specific viral

abdominal pain


Abdominal pain• Pneumonia

• Sickle cell disease

• Keto-acidosis

• Hepatitis

• Henoch-schonlein purpura

• Poisoning (e.g.lead)

• Acute porphyria

• Migraine

• Psychological causes etc etc etc……………….


Joe – don’t forget

to mention bilious

vomiting is bad


Painful things - Testes

• Torsion usually obvious

• 2 peaks, neonatal and pubertal

• Infection and torted hydatids more common in under 5’s

– blue dot sign in torted hydatid


Painful things - Testes

• Torsion usually obvious

• 2 peaks, neonatal and pubertal

• Infection and torted hydatids more common in under 5’s

– blue dot sign in torted hydatid

• Don’t forget to check urine

• Don’t forget to examine for rashes

• Almost all should be referred


Other painful things - penis

• Sore and no/mild swelling

– normal development. No treatment needed


Other painful things - penis

• Sore and no/mild swelling

– normal development. No treatment needed

• Sore and very swollen

– True balanoposthitis - rare (antibiotics)

• Poor stream and previously retractile

– Think BXO


Paraphimosis?


Other painful things – penis 2

• Paraphimosis (ouch!!!)

– Analgesia (topical and oral)

– Refer

– Don’t always need circ


Caustic ingestion

• Find out what

• Poisons unit advice

• Paediatric surgeon/ENT

• Early endoscopy/gastrostomy


Foreign bodies

Sticks at

– Cricopharyngeus (not really)

– aortic arch

– GOJ

• if in stomach forget it

– Don’t give radiotherapy!!

– Simple advice

• sifting through stools only if they have

really p***ed you off!!


Foreign bodies - tips

Beware

• Watch (button)

batteries


Foreign bodies - tips

• Open points still in oesophagus

• Symptoms but nothing visible on xray

Lateral films can be useful

• Beware drooling child

• Did they wheeze or cough?


Objectives- review

• Reviewed common paediatric surgical

emergencies

• Gained understanding of basic pathology

• Understand first/emergency treatment prior to

transfer

Nuggets in Paediatric Surgery · Bilious vomiting 2 Infant •malrotation •obstructed hernia...

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