Surgical Emergencies in Children
Dr. Wasmi Alfadhli,MD,FRCSC
Pediatric Surgery Department
Ibn Sina Hospital
9/4/2012
• They aren’t just small adults
• Size does matter! (so does age)
– Vital signs
– Fluid requirements
– Etc…
• How can we know or suspect abdominal pain
in infants?
– PERSISTANT CRYING
– REFUSAL OF FEEDING
– IRRITABILITY
– FLEXION OF THIGHS ON THE ABDOMEN
History
• Personal data:
• Chief complaint:
• History of presenting illness:
– pain?
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Associated symptoms?
Previous episodes?
Past diagnosis & treatment?
Relation to food?
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Past medical history?
Prenatal?
Nutritional?
Immunization?
Developmental?
Allergies?
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History of trauma?
Drug history?
Family history?
Recent travel?
Social history?
Physical Examination
• GENERAL INSPECTION
• ABDOMINAL EXAMINATION
• FULL EXAMINATION FOR EXTRA ABDOMINAL
CAUSES
• General Inspection:
– 1: level of consciousness
– 2:any form of distress
– 3:pain
– 4:growth:weight, length and head circumfrance.
– 5:nutritional status : obese thin or normal child?,
signs of wasting , puffy eyes?(flat buttock, loose
skin folds in the thigh and axilla)
– 5:Hydration status
• Vital signs:
– Pulse
– Blood pressure
– Temperature
– Respiratory rate
Abdominal Examination
• Inspection:
– Distention:
• A Generalized:
• Fat, feces (constipation), flatus (malabsorption, intestinal
obstruction)
• Fluid( ascites)
• Occasionally caused by grossly enlarged liver and or spleen
or muscle hypotonia
• Localized:
• upper abdomen: gastric dilatation( pyloric stenosis)
• Hepatomegaly , splenomegaly
• Lower abdomen: distended bladder, masses
• Palpation:
– Superficial:
• For tenderness, masses and rigidity
– Deep palpation:
• For tenderness ,masses, liver, spleen ,kidney ,urinary
bladder
– Percussion:
• Ascites , over mass
– Auscultation:
• For peristalsis and bruit
• Rectal Examination:
– Indication:
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1_acute abdomen
2_chronic constipation
3_rectal bleeding
4_suspected child abuse
– Inspection:
• Anal fissures, skin tags, fistula , fecal soiling , thread worms
– Palpation:
• anal tone, masses, tenderness ,look at the finger tip for
blood Stain
A CHILD WITH ACUTE
ABDOMINAL PAIN
Case 1
• 1 year Male
• Blood in stool
• What's next?
– Complete History and Physical Examination
– ABC
• DDx?
Neonates
Infants
Children
Anal fissure
Anal fissure
Anal fissure
NEC
Intussusception
Juvenile polyp
Gastroenteritis
Gastroenteritis
Midgut volvulus
Meckel's
diverticulum
UGI
haemorrhage
Meckel's
diverticulum
Intussusception
Intussusception
Milk allergy
IBD
Henoch
Schonlein
purpura
Meckel’s Diverticulum
• During the third week of fetal development,
the midgut opens into the yolk sac,remaining
temporarily connected by the vitelline duct
• As intestinal maturation proceeds,the vitelline
duct narrows. By the third month of
embryogenesis, the duct disappears
• Role of 2’s
– 2% of population
– 2:1 male:female
– 2 feet from IC valve
– Under 2yo commonest
– 2 inch long
– 2 types of mucosa
Clinical Presentation
• Symptoms are usually absent unless
complications occur
• Bleeding
• Obstruction
• inflammation (with or without perforation)
Diagnosis
• Meckel scan
Treatment
Intussusception
Incidence
• Can occur at any age
• Greatest incidence in infants btw 5 and 9mths
of age
• More than ½ of all cases occur within the 1st
year of life and only 10-25% of cases occur
after age of 2yrs
Pathophysiology
• Defined as the telescoping of one portion of
the intestine into another
• The cause is often unknown
• Thought to be viral in origin produces
enlargement of the distal ileal lymphoid tissue
(peyer’s patches) narrowing of the lumen
setting up an impending obstructing ileocolic
intussusception
• Pathologic lead point occur in 4-8% of
intussusception eg Meckel’s diverticulum,
polyp, lymphoma and appendix
• >80% are ileocolic, present with SBO and is
difficult to reduce (25% success with Ba)
Clinical manifestation
• Crampy abdo pain begins acutely
• Child may stiffen and pull legs up to the abdomen
• Hyperextension, breath holding may be followed by
vomiting
• The attack often ceases as suddenly as it started
• Later in the course
– stools may become
tinged with blood or
currant jelly
stools are passed
Diagnostic studies
½ of cases , diagnosis is suspected on plain AXR:
• Abdo mass
• Abnormal distribution of gas and fecal
contents
• Sparse large bowel gas
• Air fluid levels in bowel obstruction
• U/S
Treatment
• Hydrostatic barium enema or pneumatic
enema
• If failed or contraindicated hydrostatic barium
enema or pneumatic enema
Case 2
• 2 days old male
• Term
• BW 2.6 kg
• DDx
– Malrotation
– Atresia (duodenal,jujenal,ilial and colonic)
– Hirschsprung disease
– Meconuim ilius
– Meconuim plug
Malrotation
Embryology
• Primitive intestinal loops begin to rotate through an
arc of 270 degrees around an axis formed by the
SMA in a counter clockwise fashion
• As this rotation occurs , the 4th part of the duodenum
moves to the LUQ and fixes itself to the post abdo
wall after rotating 270degrees
• Malrotation of midgut occurs when normal
rotational process and fixation of intestine fails to
take place (10 wks)
Clinical features
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Incidence 1:500 live births
Presents in neonatal period
Approx 20-30% present after 1yr of age
Males predominate 2:1
Assd GI anomalies found in 62% eg intestinal atresia,
duodenal web, Meckels diverticulum,
intussusception..
• Onset is acute, vomiting is chief symptom (bile
vomitus)
– Be aware of a child vomiting green
• Less common symptoms: coffee ground vomiting,
abdo distension, pain and bloody stools
• In older child, chronic , vague abdo pain with
intermittent vomiting, chronic diarrhoea,
malabsorption and failure to thrive
• 50% of cases have normal physical exam
• Imaging:
– Paucity of gas in SB
– Coiled duodenum on
UGI series
– Cecal malposition on
contrast enema
Management
• Management is Operative!
– Urgent laparotomy essential to prevent gut
infarction
Atresias
Atresias
TEF
ARM
HPD
HPD
Case 3
• 6 months Male
• Scrotal swelling
• DDX of inguinal or
scrotal swelling
– Hernia
– Hydrocele
– Undescended or
retractile testes
– Testicular torsion
– Lymphadenopathy
Inguinal Hernia
• Indirect in >99% of pediatric cases
• The processes vaginalis is an elongated
diverticulum of the peritoneum which
accompanies the testicle upon its descent into
the scrotum.
• Hernia vs Hydrocele
• Epidemiology
– 1-2 inguinal hernias/100 live births
• Up to 30% in prems
• Most right-sided; 10% bilateral
– 10% complicated by incarceration
• Commonest cause of obstruction in infants
• 70% of these by 1yo
– 4-6:1 male:female
• Clinical picture
– Bulge in groin
– Progresses to off-colour, firm, tender mass
– Symptoms and signs of intestinal obstruction
– Unlike hydrocele, can feel neck of mass at distal
inguinal ring
– Transillumination suggests hydrocele
• Management
– Manual reduction
• 95% success
– Surgery for all hernias
• Emergent if not reducible
Testicular Torsion
• Could start with abd pain!!
• Sudden onset of severe testicular pain
followed by local swelling and firmness
• On inspection, the involved testicle is “highriding”
• Scrotum becomes swollen, red and tender
Testicular Torsion
• DDx
– Epididymitis/ Orchitis
– Torsion appendix testes
Testicular Torsion
• Diagnosis
– In most instances, history and gentle examination
will yield the correct diagnosis
– U/S with doppler
– Radioisotope scanning
Testicular Torsion
• Management
– Immediate surgical exploration
References
• Principles and Practice of Pediatric Surgery,
Keith T Oldham
• Pediatric Surgery, 6th Edition, Jay L. Grosfeld
• Greenfield's Surgery: Scientific Principles and
Practice
• Questions ?
