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Lenz—Ped surgery—3.25.10
Evaluation of Pediatric Patient
History
Physical Examination
Laboratory Studies
Special Studies
History
Prenatal history
Condition at Birth (APGAR, wt, term, eat)
What has changed in the last hours or days? (has the
child been eating, wt, BM)
Family History (malrotation, pyloric stenosis, etc)
Physical Examination
General Appearance (are they having retractions)
Vital Signs
Head, Neck, Chest (open airway)
Abdomen: Look, listen, feel (does the ab move
w/breath, hernias, testes, bowel sounds)
Laboratory Studies
Complete Blood Counts (helps w/the whole pic)
Electrolytes (hydration)
Urinalysis (infection, hydration)
Stool Studies (infection)
Special Studies
Chest Films (diaphragmatic hernia, pneumothorsax)
Abdominal Films (bowel gas pattern)
Spiral Computer Assisted Tomography (need to sedate,
high radiation)
Upper Gastrointestinal Series (obstruction)
Barium Enemas
Ultrasound (better test as first test than CT, no risk to
baby)
Pediatric Surgery
Group Signs and Symptoms into Disease Patterns
Decide on Diagnosis
Treatment Plan Based Diagnosis
What is an Acute Abdomen?
The Acute Abdomen is a Condition Which Requires
Urgent Diagnosis
It may or may not indicate a surgical emergency.
It often requires surgical exploration for diagnosis.
Pyloric Stenosis
Cause-Unknown
First born-more common
Males 4/5
Familial
Most are 4-6 weeks old at presentation
History- gradually worsening “spitting up” to Projectile
Vomiting
Wt loss, dehydration, infrequent stools
(nothing getting through)
Physical examination
Early appear normal, late- dehydrated,
cachectic (sometimes with tenting)
Pyloric tumor or “olive”
Ultrasound or UGI
Blood Chemistry
Early- normal
Late- Hypochloremic hypokalemic
alkalosis
muscle is like cartilage, empty belly, visible peristalsis,
dehydration, low wt
Correct metabolic problems (make sure they are peeing
before giving K)
Surgically divide the pylorus muscle without injuring
the mucosa
Discharge to home eating normally in 24-36 hours
They do really well!
Intussusception
Telescoping of one portion of bowel into another
Progressive until corrected or the bowel dies
Etiology
Adults – usually happens around a mechanical
abnormality
Children – most have no etiologic agent
Symptoms
Recurrent colicky abdominal pain
Vomiting- often repeated and severe, ¾ of
children
Pallor, sweating, dehydration and finally shock
develop if untreated
BLOODY STOOLS - 85% but not until 12-14
hours after onset (current jelly stool!)
Physical findings
Normal general appearance – to listless if late
Colicky pain often severe
Abdominal mass in 85% - sausage shaped
-Mass is firm and nontender
-sm bowel into iliocelcal valve
Dance’s sign- RLQ feels empty
Blood in stool or on rectal exam
Radiography- diagnose and treat
peds = top
adult = bottom -- lead pt
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Lenz—Ped surgery—3.25.10
-empty RLQ as SI enters colon
-use air & pressure to reduce it 1-2 times, then take to surgery –
remove bad tissue.
Appendicitis
History of patient
Symptoms/Signs of the attack
The Order of Occurrence (fever or vomit first is not
appendicitis)
History
When first noted a problem
Recent illnesses/ prior hx of similar pain/behavior
(viral illness, sick, dif behavior colicky, etc)
Medications- OTC or Rx (if on ABx suppressing some Sx
of appendicitis, steroid for asthma attack can mask what
is happening in the belly)
Prior surgery (adhesions, malrotation, etc)
Family history (have parents had appendicits, sick sib,
etc)
Signs and Symptoms
Pain (epigastric then iliac) (whole tummy hurt
yesterday, now it hurt right hear (McBurney’s pt)
Nausea, vomiting and anorexia
Local rigidity (inconstant)
Local distention (inconstant)
Fever
Constipation (due to dec intake, dehydration)
The Order of Occurrence of Symptoms
-The specific order of symptoms can be very helpful in
determining the diagnosis!!
-Fever or vomiting prior to the onset of pain is much
less likely to be appendicitis.
-Pain that comes and goes is also not likely to be
appendicitis
-Leucocytosis is often not accurate! A normal WBC does not
rule anything out!! High counts more assoc with pneumonia,
leukemia, pylonephritis if over 30,000.
-Infants rarely get appendicitis but are much more likely to have
perforation at diagnosis (at presentation).
-Ultrasound exams are much easier and more likely to be helpful
in patients with minimal abdominal fat!! Thus they are a good
study in infants and children if necessary
-Treatment- open appendectomy usually through a RLQ muscle
splitting incision or midline if suspicious of perforation.
-Larger children may have laparoscopy
-Noncomplicated cases may eat POD#1 and be home by POD#3
-Perforated patients with diffuse peritonitis may need
hospitalization for weeks
location of appendix determines Sx. Peak is spring/fall due to
viral infections – when mesenteric nodes get large it can
obstructs the lumen of appendix. Appendix is a safe home for
good bacteria.
-most common in 6-12 yr group, Dx made early so less likely to
rupture.
-over 3 days Sx they are ruptured.
iliopsoas test – hyperextend thigh = pain
obturator test = pain
Practice Questions:
1. what is an acute abdomen?
2. 4 week old male presents with projectile vomiting and you can
palpate an “olive” in his abdomen. What is the likely Dx? What
do you expect his acid/base status to be?
3. Baby presents with colicky pain and current jelly stool, What is
the most likely Dx? What physical exam and x-ray findings
would confirm your Dx?
4. Child presents with diffuse abdominal pain that is now
localized to the RLQ. Will a CBC make your diagnosis
definitive?
5. If a patient presents with fever, vomiting or intermittent pain is
appendicitis likely?
Answers:
1. The Acute Abdomen is a Condition Which Requires Urgent
Diagnosis
2. Pyloric stenosis. Early = normal, Late = Hypochloremic
hypokalemic alkalosis
3. Sausauged shaped abdominal mass & Dance’s sign- RLQ feels empty
4. this is appendicitis, CBC can be inaccurate.
5. No