Surgical Problems in Children

8/8/2019 Surgical Problems in Children

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Surgical Problems in Children

BY Ragheb Assaf ,MD



ProblemsGASTROINTESTINAL- Pyloric stenosis- Malrotation

- Midgut volvulus- Duodenal atresia- Meconium ileus- Intussusception

- Meckel¶s diverticulum- appendicitis- Hirschsprung¶s disease

GENITOURINARY ± Inguinal hernia

± Umbilical hernia- Hypospadias- Phimosis/paraphimosis- Cryptorchidism- Hydrocele- Testicular torsion

OBJECTIVES

-Recognize-Diagnose-C onsult surgery



Pyloric stenosisHypertrophy of the gastric outlet

1:150 males, 1:750 females2-12 weeks of age

Repetitive vomitingProjectileNon-bilious

DehydrationHypochloremic alkalosis

ExamVisible peristaltic wavePalpable ³olive´ to right of umbilicus



Pyloric stenosis: DiagnosisUG I

Delayedpassage of barium throughthickened pyloricchannel

U ltrasound

Thickened,elongatedpyloricchannel



Pyloric stenosis :treatment

Hypertrophy of pylorus

E ndoscopic balloon dilation

S urgical tx = pyloromyotomy



Surgical treatment



MalrotationFailure of midgut to rotateinto normal anatomic

position duringdevelopment - Colon and cecum in left - Duodenum on right side

- Bilious vomiting- Peritoneal (Ladd) bandscause partial bowel obstruction

- High risk for...

Duodenum toright of spine

C ecum in leftabdomen



Midgut volvulus

Twisting of bowel around itsmesentery and vascular supply

Leads to ischemia, infarction, perforation, necrosisPresentation: lethargy, abdominal distention, bloody stools

!SURGICAL

EMERGENCY



MALROTATION

M ust consider in every infantwith bilious emesis

30% present within first week of life50% within first monthM idgut volvulus with necrosisdisastrous

C an lead to SBS, death



C LINI C AL P RE S ENTATION of

MALROTATION

Sudden onset of bilious emesis in 95 %

A bdominal distention common

Blood stool +

Bloody vomitus or diarrhea in 30%



RADIOLOGI C DX of

MALROTATIONKU B:Gasless abdomen,SBO,

³double bubble´

C ontrast study: spiral or corkscrew appearanceU TS: reversed positionof S MA/ S MV

Study MUST beexpeditious



P REO P ERATIVE P RE P ARATION:

MALROTATIONW

ITH VOLVULU

SL abs / unnecessaryM ortality remains as high

as 28 %P reoperative preparation?? N O N E !!

... GO TO OR« . QUICK LY



O P ERATIVE C ORRE C TION of

MALROTATION

L add procedure

P osition of corrected malrotationSmall bowel descends on RightL arge bowel on L eft A ppendix potentially in L U Q p Removed

Role of second look operation



Duodenal atresiaObliteration of lumen

Failure to recanalize

Neonatal bilious vomiting Associations

Prematurity Congenital heart defects

Trisomy 21C omplete

small bowelobstruction

Doubl ebubbl e sign

!SURGICAL

EMERGENCY



Meconium ileusCYSTIC FIBROSIS

First manifestation in 15%of CF casesThick meconium impactsin ileum Abdominal distention

Bilious vomiting

Risk for VolvulusPerforation

M icrocolonwithmeconiumplugs

!SURGICAL

EMERGENCY



I ntussusceptionM ost common cause of intestinal obstructionbetween 3 mo - 6 yrs2 /3 cases occur <2 yrsM ale /F emale=4:175-95 % Ileocolic>9 0% idiopathic;M eckel¶s, P eyer¶spatches, tumors, polyps Telescoping of proximal bowel

into distal (Terminal Ileum intoCecum depicted in diagram)



IntussusceptionTelescoping of onesegment of bowel intoanother

Ileocolonic most common6 mos ± 3 years old

Progressive courseIntermittent acute abd. pain

VomitingBloody stools (currant jelly)Fever, lethargy Palpable sausage-shaped mass in upper abdomen



I ntussusception : PresentationA bdominal pain,vomiting and rectalbleeding triad seen in <

1 /3 of cases .85 % display only colickyabdominal pain often 1-5minutes of crying andpain separated by 3 -30

minutes of nl behavior 75 % have vomiting(develops after 6-12 hrs)40% rectal bleedingU p to 1 0% : L ethargyonly

U/S demonstrating targetor donut sign



I ntussusception : D iagnosisP hys Exam: 25-89 % may have variablytender sausage shapedmass; Dance¶s sign:empty R L QU /S: target,pseudokidney,

radiologist dependent; if high suspicion, order thebarium enema P lain films ±target sign,

crescent , and obstruction,30% may be normal



I ntussusception : M anagementEnema: diagnostic & therapeutic, ³coiledspring´

Surgery must be consulted prior to study.

Barium vs . A ir- 80% correction if within first 12-24 hrs .

A ir Enema- safer if perforation

5-10%

recurrence rate in first 24-48h after barium enema reductionIf free air on films or signs of peritonitis, do notadminister barium, prepare child for surgery



Intussusception Management

Ultrasound : Hydrostatic pressure reduces theintussusception

Surgeon must be involved directly If enema reduction failsSmall bowel intussusceptions requiresurgical reduction



Intussusception

Terminal ileum telescopedinto cecum



A ppendicitis80 ,000 cases in children /year /in U S A

Rare in children < 2years20 -4 0% misdiagnosed on initial exam50 -7 0% perforation rate in pre-schoolM ortality Rates of 5 % in perforated vs0 .1% in non-perforated appendicitis



A ppendicitis

P athophysiology: obstruction of appendix by fecalith or lymphoidtissue causes congestion,

distention, ischemia, infection &perforation .



H istoryM igration of pain from initial periumbilicalto R L Q was 64 % sensitive and 82 %

specificA norexia is the most common of associated symptoms

V omiting is more variable, occuring inabout ½ of patients



Physical Ex amF indings depend on duration of illnessprior to exam .

Early on patients may not have localizedtendernessWith progression there is tenderness to

deep palpation over M cBurney¶s point



Physical Ex amM cBurney¶s P oint: just below the middleof a line connecting the umbilicus and

the A S ISRovsing¶s: pain in R L Q with palpation toLL Q

Rectal exam: pain can be mostpronounced if the patient has pelvicappendix



Physical Ex amF ever: another late finding .

A t the onset of pain fever is usually notfound . Temperatures > 3 9 C are uncommon infirst 24 h, but not uncommon after

rupture



D iagnosisImaging studies: include X-rays, U S, C TXrays of abd are abnormal in 24-95 %

A bnormal findings include: fecalith,appendiceal gas, localized paralyticileus, blurred right psoas, and free air

A bdominal xrays have limited use b /c thefindings are seen in multiple other processes



D iagnosisL imitations of U S:retrocecal appendixmay not bevisualized,perforations may bemissed due to returnto normal diameter

U/S demonstrating thickenednon-compressible, fluid filledappendix

U /S vs . C T: Sensitivityand Specificity are90%/ 97 % and94 %/ 94 % , respectively



D iagnosisC T appears tochange management

decisions anddecreasesunnecessaryappendectomies ingirl, but it is not asuseful for changingmanagement in boy .

CT showing fluid filledappendix (diameter >6mm)with fat stranding



T reatmentA ppendectomy is the standard of careP atients should be N P O, given IVF , andpreoperative antibioticsA ntibiotics are most effective when givenpreoperatively and they decrease post-

op infections and abscess formation



Hirschsprung¶s diseaseCongenital absence of ganglioncells in distal rectum

- and varying distance proximally Lack of peristalsis causes colonic obstruction Abdominal distentionFailure to pass meconiumFever and diarrhea suggest ³toxic megacolon´ !

SURGICALEMERGENCY



Hirschsprung¶s

AX R:obstructivepattern

B arium enema:Dilated proximalcolon witht ransi t i o n z o ne

S uction rectal bx

A b sence of g an gl i o n ce ll sin myentericplexus



Hirschsprung¶s

Surgical treatment 1. Colostomy 2. Pull-through and removal of

aganglionic segment



T ransanal pull-through



Umbilical herniaIncomplete closure of umbilical ring fasciaMore common in prematureand African-AmericaninfantsUsually close by 2-4 yrsRefer to surgery if:

Larger than 1.5 cm at 2 yrsPresent after 4 yrs

Supraumbilical hernia :Refer to surgery



Hypospadias Abnormal low position of urethral meatus

Absence of ventral foreskin Associations

Undescended testes

Urinary tract anomaliesManagement

Avoid circumcisionRefer to surgeon



Phimosis vs. Paraphimosis

P himosis: inability toretract foreskinTx: dorsal slit or

circumcision

P araphimosis: foreskin retractedbehind coronal groove; tourniquet toglans

Tx: circumcision



Scrotal swellingPAINLESS

Hydrocele

VaricoceleSpermatoceleInguinal hernia

PAINFULTesticular torsion

EpididymitisOrchitisIncarcerated hernia



Hydrocele

M obileTransilluminatesSpontaneous resolution



CryptorchidismUndescended testicle(s)

Spontaneous descent doesnot occur beyond age 1 yr

Bilateral in 1/3 of cases Associations

Inguinal herniaHypospadias

Higher incidence of Testicular torsionInfertility Cancer in cryptorchid testis



CryptorchidismEndocrine eval.

Refer early: 6-12 mos of agehCG stimulation test

Can aid in descent

Karyotype if hypospadiasco-exists

Surgery Orchidopexy

Usually in1- 2 nd yr of life



Testicular torsionTwisting of testis around spermatic cord

Caused by abnormal fixationof testis to scrotumVascular supply compromised

Acute painful scrotal swelling

Severe tendernessRedness or dusky color Testis elevated Cremasteric reflex absent

!SURGICALEMERGENCY



management

In the patient with acute surgical scrotalpain ,immediate surgical consultation is

essential .

Surgical exploration , detorsion and

fixation .



O utcome

Ischemic testicular damage related tothe number of turns of the spermatic

cord and the duration of torsion .A ll cases with a torsion > 3 60* and > 24h

duration will have testicular loss or severe

atrophy if the testis left in situ .



What to do?A lways undress the childfor examDon¶t forget

Intussusception inlethargic childrenU tilize imaging liberallywhen child looks sickand know your

radiologist¶s expertise

A ny type of blood instool may be due toIntussusception (not only

currant jelly)V omiting in infantsshould not be takenseriouslyBe conservative with

children w/

unclear dxBe sure that the parent(s) understand return precautions . If

they do not, then observe child



Q uestions or C omments

Surgical Problems in Children

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