pediatric non-traumatic surgical emergencies
DESCRIPTION
Dr. H. Flageole Department of Surgery McMaster Children’s Hospital October 15, 2008. Pediatric non-traumatic Surgical Emergencies. Objectives. To familiarize the resident with non-traumatic emergencies - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/1.jpg)
Dr. H. FlageoleDepartment of SurgeryMcMaster Children’s HospitalOctober 15, 2008
![Page 2: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/2.jpg)
Objectives
To familiarize the resident with non-traumatic emergencies
To familiarize the resident with surgical emergencies encountered in the newborn and early childhood periods.
Identify symptoms of significant disease
Recognize life-threatening surgical conditions
![Page 3: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/3.jpg)
Acute Abdomen
Often unable to get history Importance of congenital anomalies Make sure stomach and bladder are
empty Differential diagnosis
GI surgical and medical problems urinary
![Page 4: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/4.jpg)
![Page 5: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/5.jpg)
ADMISSION TO SURGICAL WARD WITH ACUTE ABDOMINAL PAIN
NSAP 30%Acute appendicitis 28%Constipation 11%URTI 8%UTI 6.9%Gastroenteritis 3.6%Pneumonia 2.2%SBO (incl. Intussusception) 2.2%Mesenteric adenitis (operated) 2.2%Abdominal injuries 1%Hepatitis 1%Torsion of testisPancreatitis < 1%OMDiabetic acidosis
![Page 6: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/6.jpg)
History
Vomiting: reflex vs. obstructive bilious or non-bilious
Abdominal pain: visceral vs. peritoneal crampy vs. constant
GI bleed: colour, amount, signs, association with pain
![Page 7: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/7.jpg)
General Management
• ABC
• Fluids and electrolytes
• NG tube
• Antibiotics
• Pain control
![Page 8: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/8.jpg)
![Page 9: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/9.jpg)
![Page 10: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/10.jpg)
Pyloric Stenosis• Incidence
– Rare in blacks
– 0.5 - 2/1000 live births
• Age: 3 weeks - 3 months
• Non-bilious vomiting
• Olive is not easily palpable
• Ultrasound is very accurate
![Page 11: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/11.jpg)
Pyloric Stenosis
• Beware of acid-base and electrolyte imbalances.
•Hypokalemic, hypochloremic metabolic alkalosis
• surgical complications
•Wound infection – 10%
•Accidental opening of GI tract
![Page 12: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/12.jpg)
![Page 13: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/13.jpg)
![Page 14: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/14.jpg)
![Page 15: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/15.jpg)
![Page 16: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/16.jpg)
![Page 17: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/17.jpg)
Pre-op management
IV fluid:
If alkalotic, when is it safe to operate and why?
![Page 18: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/18.jpg)
![Page 19: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/19.jpg)
Intussusception
CLINICAL SUSPICION
X-RAY
U/S
REDUCTION BY BARIUM / AIR ENEMA
![Page 20: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/20.jpg)
What is the intussuscipiens?
![Page 21: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/21.jpg)
![Page 22: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/22.jpg)
Intussusception
• Age: 3 months – 3 years
• Crampy abdominal pain
• Traction of the mesentery pallor, lethargy
•typically in younger infants
• Blood & mucous in stool (red current jelly)
![Page 23: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/23.jpg)
Intussusception
• Crampy abdominal pain 80%
• Vomiting (early=reflex) 60-80%
• Rectal bleeding 30-50%
• Palpable mass 30-60%
• Others
– Lethargy, diarrhea, fever
![Page 24: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/24.jpg)
![Page 25: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/25.jpg)
![Page 26: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/26.jpg)
![Page 27: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/27.jpg)
Barium enema
![Page 28: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/28.jpg)
Air enema
![Page 29: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/29.jpg)
Intussusception
• Beware of the 15% who are atypical
• Young infants are often just lethargic
• Don’t hesitate to do an ultrasound when the history is suggestive
![Page 30: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/30.jpg)
![Page 31: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/31.jpg)
In older children, suspect a lead point.
What lesions could act as lead points?
![Page 32: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/32.jpg)
Lead Points
Meckel’s diverticulum Polyps Henoch-Schonlein purpura (HSP) Lymphoma Intestinal duplications
![Page 33: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/33.jpg)
Treatment
Success rate of enema reduction around 80%
Small risk of perforation (2.5%) What would you do?
Laparoscopic reduction When there is lead point, usually
cannot be reduced. Resection with primary anastomosis
![Page 34: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/34.jpg)
![Page 35: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/35.jpg)
Midgut Volvulus
• Secondary to MALROTATION
• Age: 80% under 12 months old
• Sudden onset of GREEN vomiting
• Exam and X-rays may be normal initially
![Page 36: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/36.jpg)
Who knows?
- Normal position of Ligament of Treitz?- Normal position of IC valve?- What we mean by base of mesentery?- Why does malrotation predispose to
volvulus?
![Page 37: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/37.jpg)
![Page 38: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/38.jpg)
![Page 39: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/39.jpg)
![Page 40: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/40.jpg)
![Page 41: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/41.jpg)
![Page 42: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/42.jpg)
![Page 43: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/43.jpg)
![Page 44: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/44.jpg)
Who knows the steps of a Ladd’s procedure?
![Page 45: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/45.jpg)
Ladd’s procedure
Reduction of volvulus Division of Ladd’s bands Widening of mesenteric base Appendectomy
![Page 46: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/46.jpg)
![Page 47: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/47.jpg)
Small Bowel Obstruction
![Page 48: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/48.jpg)
5 pediatric causes
![Page 49: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/49.jpg)
Incarcerated hernia
congenital anomaly/band, internal hernia
Volvulus
Post-operative adhesions
Febrile obstruction: ruptured appendicitis
![Page 50: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/50.jpg)
A small bowel obstruction in a virgin abdomen is a surgical indication
![Page 51: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/51.jpg)
![Page 52: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/52.jpg)
Acute Appendicitis
Symptomatology in 691 Patients < 12 Years
• Pain 98.7%
• Vomiting 81.5%
• Urinary symptoms 14%
• Diarrhea 10%
![Page 53: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/53.jpg)
Acute AppendicitisJ Pediatr Surg 36:5, 2001 pp 780-783
Number of patients 454
Goal: to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography.
![Page 54: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/54.jpg)
Clinical Outcomes
Outcome CG (n=263) SG (n=191) P valuePre-opobservation(%)
4.2 19.4 <0.001
ER to OR (hr) 4.93 8.04 <0.001% Negativeappendectomy
5.7 13.1 0.006
% complicatedappendicitis
37.3 35.1 NS
% post-opabscess
1.2 4.4 0.038
LOS 2.35 2.82 NS
![Page 55: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/55.jpg)
Conclusions
U/S should be reserved for patients who cannot receive a diagnosis on clinical grounds alone.
To obtain an U/S should be a surgical decision after a surgical evaluation
Greater role in post-pubertal females
![Page 56: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/56.jpg)
What are the radiological criteria to make the diagnosis of acute appendicitis?
![Page 57: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/57.jpg)
Size > 6mm Non – compressibility Corresponds to area of maximal
tenderness Identification of a fecalith
Free fluid Fat stranding
![Page 58: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/58.jpg)
![Page 59: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/59.jpg)
CT & Acute Appendicitisin Adults
Sensitivity: 90% for CT 76% for clinical exam (p<0.0005)
Specificity: 97%
Bettina Siewert et al., Beth Israel Hospital Harvard
Medical School 1/1997
![Page 60: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/60.jpg)
Used infrequently Occasionally in older, obese
teenagers Concern about radiation
CT & Acute Appendicitisin Children
![Page 61: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/61.jpg)
![Page 62: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/62.jpg)
Gastrointestinal Bleeding
• Upper GI: tarry, melena stool
• Lower GI: red blood, clot
• Injury to mucosa: mixture of blood & mucous
![Page 63: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/63.jpg)
GI Bleeding
• Rarely life-threatening
• Upper GI causes:
– Most: ASA, viral
– Massive bleed: varices, ulcer
• Lower GI causes
– Most: fissure, polyp, IBD, HUS etc.
– Massive bleed: Meckel’s diverticulum, intestinal duplication.
![Page 64: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/64.jpg)
![Page 65: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/65.jpg)
Who knows the rule of 2’s?
![Page 66: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/66.jpg)
2% of population 2 types of mucosa (gastric and
pancreatic) 2 feet from the ileocecal valve 2 types of presentation
Obstruction Bleeding
2 inches long 2 other things I likely forgot
![Page 67: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/67.jpg)
![Page 68: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/68.jpg)
Meckel’s diverticulum
Will cause massive, painless LGI bleed to the point of requiring transfusion.
It is important to give H2 blockers for 3-5 days prior to doing a Meckel scan to increase its sensitivity.
![Page 69: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/69.jpg)
![Page 70: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/70.jpg)
Polyps
• Solitary or multiple
• Histology
– Hyperplastic
– Inflammatory - UC, nodular lymphoid HP
– Hamartomas-Juvenile, Peutz Jeghers
– Adenomatous (neoplastic) - Familial,Turcots syndromes
![Page 71: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/71.jpg)
![Page 72: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/72.jpg)
![Page 73: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/73.jpg)
![Page 74: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/74.jpg)
Polyps
Juvenile polyps will cause LGI bleed usually solitary In rectosigmoid (sometimes felt on DRE) May protrude or auto-amputate Endoscopic removal
Small bowel polyps will cause??
![Page 75: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/75.jpg)
![Page 76: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/76.jpg)
Foreign Body Ingestion
• X-ray: foreign body search
•soft tissues neck, CXR, AXR
• Most foreign bodies will pass through the GI tract uneventfully
• FB in the esophagus, alkaline batteries and long sharp ones must be removed.
![Page 77: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/77.jpg)
![Page 78: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/78.jpg)
![Page 79: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/79.jpg)
![Page 80: Pediatric non-traumatic Surgical Emergencies](https://reader035.vdocuments.net/reader035/viewer/2022062305/56815928550346895dc64f0c/html5/thumbnails/80.jpg)