Pediatric Surgical
Emergencies
Division of Pediatric Surgery
Patty Lange
September 2005
Objectives
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Understand what constitutes an emergency
Understand the basic patholophysiology of
pediatric surgical emergencies
Recognize signs and symptoms of intestinal
obstruction, peritonitis, sepsis
Learn the basic diagnostic techniques in surgical
emergencies
Learn management strategies for the various
surgical emergencies
Outline
 Appendicitis
 Intussusception
 Pyloric
Stenosis
 Incarcerated Inguinal hernia
 Hirschsprung’s Enterocolitis
 Malrotation with volvulus
Outline Continued
 What
are the important points about the
history?
 What are the pertinent physical findings?
 What is the differential diagnosis?
 What further workup is needed?
 How is the problem managed?
 When/if to do surgery?
 Postop management
Case 1
 6mo
infant with vomiting, poor po intake,
abdominal distension
Case 1
 6mo
infant with vomiting, poor po intake,
abdominal distension
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Previous 33wk gest age
Non-bilious emesis
Looks ill
Some respiratory problems as neonate
No history of surgeries, no meds
Physical exam---
KUB
Inguinal Hernias in children
Patent Processus Vaginalis
Not so subtle Sometimes
High Ligation of Sac
Case 2
 6mo
infant with vomiting, poor po intake,
abdominal distension
Case 2
 6mo
infant with vomiting, poor po intake,
abdominal distension
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Otherwise healthy infant, no previous feeding
intolerance
Looks well, mom says intermittent fussiness
Mom says pt passed reddish, thick-mucous
stool
Physical exam--
Intussusception
“Currant jelly stool”
KUB
KUB
Intussusceptum
Contrast Enema
Incomplete Air Reduction
Perforation and Necrosis
Case 3
 6mo
infant with vomiting, poor po intake,
abdominal distension
Case 3
 6mo
infant with vomiting, poor po intake,
abdominal distension
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Mom says not tolerating his bottle today.
Began having green emesis, has not had a
wet diaper today
Baby looks ill, not very reactive on exam
PE--Abd distended, tense, tender
Bilious Emesis is BAD
Bilious Emesis is Malrotation
with Volvulus Until Proven
Otherwise
Embryology
Embryology
Volvulus
UGI
Duodenal-jejunal
junction
UGI
“Bird’s beak”
Volvulus and Ischemia
Dividing Ladd’s Bands
Widening the Mesentery
Positioning the Viscera
Case 4
 5wk
old male infant with persistent emesis
for 2 weeks
Case 4
 5wk
old male infant with persistent emesis
for 2 weeks
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Mom says baby throws up almost every
feed—getting worse and more forceful,
emesis looks like the formula she feeds him
On Prevacid for reflux diagnosed 1 wk ago
Using rice cereal to thicken feeds but no
improvement
Not wetting as many diapers
Pyloric Stenosis--US
UGI
Resuscitation
 Electrolytes
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Hypokalemia
Hypochloremia
Elevated bicarbonate
Indirect hyperbilirubinemia (glucuronyl
transferase deficiency)
 Importance

typically show
of adequate resuscitation
Anesthetic implications
HPS
Thickened Pylorus
Pyloromyotomy
Pyloromyotomy Completed
Case 5
4
day old female presents to ED with
lethargy, abdominal distension, emesis
Case 5
4
day old female presents to ED with
lethargy, abdominal distension, emesis
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37 wk gestation, Twin A
Small ASD, no other medical probs
Mom says pt not making as many diapers as
her twin sister and not eating as much
PE—abd distension, rectal exam—(make
sure you stand to the side!)
Hirschsprung’s Disease
KUB
Hirschsprung’s
Contrast Enema
Transition Zone
Leveling Colostomy
(+)
(-)
Case 6
 6yo
male, otherwise healthy, presents to
pediatrician with abdominal pain and
nausea
Case 6
 6yo
male, otherwise healthy, presents to
pediatrician with abdominal pain and
nausea
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Dad says pt started complaining about abd
pain yesterday after school (1st day of school)
Ate dinner but then woke up around midnight
c/o pain again
Vomited once this am
Walks hunched over
H/O occasional constipation
KUB
US
Abdominal CT
Psoas sign
Laparoscopic Appendectomy
Summary
 Bilious
Emesis is BAD!! Bilious emesis is
malrotation with volvulus until proven
otherwise
 Resuscitation prior to surgery is very
important
 Clinical “Gestalt” is often the best
diagnostic tool