pediatric surgical emergencies robert w. letton, jr., md associate professor, department of surgery...
TRANSCRIPT
Pediatric Surgical Emergencies
Robert W. Letton, Jr., MDRobert W. Letton, Jr., MDAssociate Professor, Department of SurgeryAssociate Professor, Department of Surgery
Pediatric SurgeryPediatric Surgery
Introduction
Bowel ObstructionBowel Obstruction AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception
NECNEC The Acute GroinThe Acute Groin Bleeding Meckel’sBleeding Meckel’s Foreign BodiesForeign Bodies
Question 1?
Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis?
Answer
Because unlike when Stan sees Wendy in Southpark©, it usually means bowel obstruction or necrosis in our patients!
Bowel Obstruction
Diagnosis often age specificDiagnosis often age specific Bilious vomiting in the infant and child is a Bilious vomiting in the infant and child is a
surgical emergency until proven otherwisesurgical emergency until proven otherwise Difficult to tell when volvulus is presentDifficult to tell when volvulus is present Child may look surprisingly good until it’s Child may look surprisingly good until it’s
too latetoo late
Atresia
Usually presents the first few days of lifeUsually presents the first few days of life Child may feed well for a day or two with Child may feed well for a day or two with
distal atresiadistal atresia Duodenal atresia often diagnosed on Duodenal atresia often diagnosed on
antenatal U/Santenatal U/S Atresias can occur anywhere in GI tract Atresias can occur anywhere in GI tract
from pharynx to anusfrom pharynx to anus
Atresias
Esophageal: aspirate feeds immediately, Esophageal: aspirate feeds immediately, OG tube won’t passOG tube won’t pass
Duodenal: bilious vomiting immediately, Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of “double bubble” on KUB with absence of distal gasdistal gas
Jejunal: usually present 1Jejunal: usually present 1stst 24 hours, large 24 hours, large dilated proximal loop or loopsdilated proximal loop or loops
Atresias
Ileal: may take 24-48 hours before bilious Ileal: may take 24-48 hours before bilious emesisemesis
Colonic: rare, may present with bilious Colonic: rare, may present with bilious emesis after 2-3 daysemesis after 2-3 days
Anal: should be diagnosed at birth, often a Anal: should be diagnosed at birth, often a perineal fistula is labeled normalperineal fistula is labeled normal
Atresias may be multiple
Jejunal Atresia
Imperforate Anus: Anal atresia
Hirschsprung’s Disease
Congenital colonic aganglionosisCongenital colonic aganglionosis Physiologic obstruction Physiologic obstruction
May present first few days to weeks of lifeMay present first few days to weeks of life Short segment disease often tolerated for Short segment disease often tolerated for
monthsmonths Starts at anus and extends proximally a Starts at anus and extends proximally a
variable distancevariable distance
Hirschsprung’s Disease
Hirschsprung’s Disease
Toxic Megacolon
Severe enterocolitisSevere enterocolitis Very rare to get with idiopathic constipationVery rare to get with idiopathic constipation Usually only seen with Hirschsprung’s Usually only seen with Hirschsprung’s
Disease or Ulcerative ColitisDisease or Ulcerative Colitis NG decompression, IV fluids, IV antibioticsNG decompression, IV fluids, IV antibiotics Mortality 20-30% in some studiesMortality 20-30% in some studies
Toxic Megacolon
Hirschsprung’s in an 8 year old
Believe it or Not . . .
Malrotation
Normal
Malrotation
Most often presents during the first few Most often presents during the first few months of lifemonths of life
Infant with acute onset of bilious emesisInfant with acute onset of bilious emesis May be diagnosed on UGI for other reasonsMay be diagnosed on UGI for other reasons Malrotation is a surgical urgency due to the Malrotation is a surgical urgency due to the
possibility of volvuluspossibility of volvulus VOLVULUS IS A SURGICAL VOLVULUS IS A SURGICAL
EMERGENCYEMERGENCY
Malrotation
Malrotation
Volvulus
Volvulus
Malrotation most common condition Malrotation most common condition resulting in midgut volvulusresulting in midgut volvulus
Can have volvulus with normal rotationCan have volvulus with normal rotation omphalomesenteric remnantomphalomesenteric remnant internal herniainternal hernia DuplicationDuplication Adhesive small bowel obstructionAdhesive small bowel obstruction
Small Bowel Obstruction
Meckel’s
Intussusception
Inversion of the bowel upon itself Inversion of the bowel upon itself secondary to a lead pointsecondary to a lead point
Juvenile intussusception most often Juvenile intussusception most often idiopathicidiopathic Also secondary to Meckel’sAlso secondary to Meckel’s
Presents 6 months to 2 years of agePresents 6 months to 2 years of age As early as 1 monthAs early as 1 month
Intussusception
Acute painful episodes followed by periods Acute painful episodes followed by periods of lethargyof lethargy
When incarcerated progress to continuous When incarcerated progress to continuous lethargylethargy
May or may not have “currant-jelly” stoolMay or may not have “currant-jelly” stool But often stool is heme positiveBut often stool is heme positive
Rule out with a left lateral decubitus filmRule out with a left lateral decubitus film
Intussusception
Intussusception
Intussusception
7% chance of recurrence after ACE 7% chance of recurrence after ACE reductionreduction Usually recur in 48 hoursUsually recur in 48 hours
Operative exploration warranted on second Operative exploration warranted on second recurrence to R/O pathologic lead pointrecurrence to R/O pathologic lead point
Recurrence after surgery rare but possibleRecurrence after surgery rare but possible Post-op intussusception can occur after any Post-op intussusception can occur after any
surgerysurgery
Bowel Obstruction
Bowel Obstruction: Initial Management NG or OG to low wall suction (NPO!!)NG or OG to low wall suction (NPO!!) Hydrate and replace lossesHydrate and replace losses
10 cc/kg of crystalloid IS NOT AN 10 cc/kg of crystalloid IS NOT AN ADEQUATE BOLUS!!ADEQUATE BOLUS!!
Antibiotics if suspect perforation or necrosisAntibiotics if suspect perforation or necrosis Acute Abdominal SeriesAcute Abdominal Series Transfer to appropriate facilityTransfer to appropriate facility
Necrotizing Enterocolitis
Incidence: 25,000 per year; 10-70% mortalityIncidence: 25,000 per year; 10-70% mortality Most common serious GI disease of low Most common serious GI disease of low
birth-weight infantsbirth-weight infants Etiology is unknownEtiology is unknown Most common in terminal ileum and colonMost common in terminal ileum and colon
““pan-necrosis” involves >75% of gut and pan-necrosis” involves >75% of gut and occurs in 19% of patients; mortality occurs in 19% of patients; mortality approaches 100%approaches 100%
Necrotizing Enterocolitis
Abdominal distention is most common Abdominal distention is most common findingfinding
Feeding intolerance with bilious NG Feeding intolerance with bilious NG aspirateaspirate
Palpable bowel loops and crepitus Palpable bowel loops and crepitus Edema and erythema of abdominal wall Edema and erythema of abdominal wall
peritonitisperitonitis Rectal bleeding is common: gross and/or Rectal bleeding is common: gross and/or
occultoccult
NEC Abdominal Films
Necrotizing Enterocolitis
Initial medical management unless evidence Initial medical management unless evidence of necrosis/perforationof necrosis/perforation
OG decompressionOG decompression Broad spectrum antibioticsBroad spectrum antibiotics NPO, TPN, fluid resuscitationNPO, TPN, fluid resuscitation Abdominal film surveillanceAbdominal film surveillance Serial labs: CBC with platelets, ABG, CRPSerial labs: CBC with platelets, ABG, CRP
NEC Abdomen
NEC Pneumoperitoneum
NEC Ileal Involvement
NEC Totalis
The Acute Groin
Testicular Torsion
Most important, not most common causeMost important, not most common cause Peak incidence 13 to 16 years of agePeak incidence 13 to 16 years of age Before age 16Before age 16
60% torsion testis appendix, 30% 60% torsion testis appendix, 30% testicular torsion, 10% epididymitistesticular torsion, 10% epididymitis
Sudden testicular pain, nausea, palpation Sudden testicular pain, nausea, palpation exquisitely tender, horizontal lie, exquisitely tender, horizontal lie, hemiscrotum red, edematoushemiscrotum red, edematous
Testicular Torsion
Testicular Torsion
Loss of cremasteric reflex with torsionLoss of cremasteric reflex with torsion Torsion of appendix testis similar: point Torsion of appendix testis similar: point
tender at upper pole, testicle less tendertender at upper pole, testicle less tender Ultrasound and/or nuclear blood flow study Ultrasound and/or nuclear blood flow study
MAYMAY be of benefit in adolescents be of benefit in adolescents smaller children difficult to perform smaller children difficult to perform
and/or interpretand/or interpret Do not delay surgical exploration for Do not delay surgical exploration for
studiesstudies
Testicular Torsion
Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997
Inguinal Hernia
From Atlas of Pediatric Surgery, Ashcraft, 1994
Incarcerated Inguinal Hernia
Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997
Incarcerated Hernia
If unable to reduce: urgent operative If unable to reduce: urgent operative exploration (NPO)exploration (NPO)
If able to reduce without sedation: urgent If able to reduce without sedation: urgent surgical referral with repair soonsurgical referral with repair soon
If extremely difficult (sedation, surgical If extremely difficult (sedation, surgical referral): repair next dayreferral): repair next day
Watch child for obstructive symptomsWatch child for obstructive symptoms
Meckel’s
In newborns and infants present as bowel In newborns and infants present as bowel obstruction (volvulus, intussusception)obstruction (volvulus, intussusception)
Bleeding most common presentation in Bleeding most common presentation in childrenchildren
Painless, massive, requiring transfusionPainless, massive, requiring transfusion Bleeding due to peptic ulceration at the base Bleeding due to peptic ulceration at the base
of diverticulumof diverticulum
Meckel’s
Can diagnose with a Technetium scanCan diagnose with a Technetium scan Pretreatment with Cimetidine enhances Pretreatment with Cimetidine enhances
uptake of tracer and improves sensitivityuptake of tracer and improves sensitivity Often have to repeat scan more than onceOften have to repeat scan more than once If a 1-3 year old has two significant LGI If a 1-3 year old has two significant LGI
bleeds requiring transfusion, exploration bleeds requiring transfusion, exploration warranted even if scan negativewarranted even if scan negative Polyps usually don’t need transfusionPolyps usually don’t need transfusion
Meckel’s
Foreign Bodies
Laryngeal: Hoarseness, aphonia, dyspnea, Laryngeal: Hoarseness, aphonia, dyspnea, cyanosiscyanosis Hot dog most common cause of fatal Hot dog most common cause of fatal
aspirationaspiration Tracheal: asthmoid wheeze, subglottic Tracheal: asthmoid wheeze, subglottic
“thud”“thud” Bronchial: period of coughing and Bronchial: period of coughing and
wheezing, then asymptomatic intervalwheezing, then asymptomatic interval
Bronchial Foreign Body
Check valve obstructionCheck valve obstruction partial obstruction inspiration, complete partial obstruction inspiration, complete
obstruction expirationobstruction expiration obstructed lung expanded during obstructed lung expanded during
expirationexpiration Stop valve obstructionStop valve obstruction
complete obstruction of complete obstruction of inspiratory/expiratory phaseinspiratory/expiratory phase
distal atelectasisdistal atelectasis
Check Valve Obstruction
Stop Valve Obstruction
Treatment
Removal under direct vision as soon as Removal under direct vision as soon as possible by a “skilled” bronchoscopistpossible by a “skilled” bronchoscopist removal with grasper or balloon catheterremoval with grasper or balloon catheter
Occasionally will need thoracotomy to Occasionally will need thoracotomy to “milk” FB into position for scope“milk” FB into position for scope
Laryngeal FB may require emergent Laryngeal FB may require emergent cricothyrotomycricothyrotomy
Complications
Loss of airwayLoss of airway partial obstruction object may become partial obstruction object may become
complete with paralysiscomplete with paralysis PneumothoraxPneumothorax
vigorous positive pressure ventilationvigorous positive pressure ventilation Post-obstructive pneumoniaPost-obstructive pneumonia
Esophageal Foreign Bodies
Coins most commonCoins most common Four cardinal areas or narrowingFour cardinal areas or narrowing
below the cricopharyngeus musclebelow the cricopharyngeus muscle level of the aortic archlevel of the aortic arch carinacarina just above the diaphragmjust above the diaphragm
Signs and Symptoms
Episode of coughing, choking and droolingEpisode of coughing, choking and drooling Pain and dysphagiaPain and dysphagia After an asymptomatic period get signs of After an asymptomatic period get signs of
obstructionobstruction Pain, fever, and shock occur with Pain, fever, and shock occur with
perforationperforation
Diagnosis
History suggestsHistory suggests CXR/Neck films show radiopaque coins CXR/Neck films show radiopaque coins
and foreign bodiesand foreign bodies May need contrast study to diagnoses May need contrast study to diagnoses
radiolucent objectsradiolucent objects
Esophageal Coin
Esophageal “Pop Top”
Treatment
Removal of foreign body under direct Removal of foreign body under direct vision with rigid esophagoscopevision with rigid esophagoscope
If object has passed into stomach, If object has passed into stomach, observation warrantedobservation warranted
Foley catheter removal possible if less than Foley catheter removal possible if less than 24 to 48 hour history24 to 48 hour history
Post removal CXRPost removal CXR
Complications
Aspiration pneumoniaAspiration pneumonia Esophageal strictureEsophageal stricture Esophageal perforationEsophageal perforation
secondary to erosionsecondary to erosion iatrogeniciatrogenic
Small bowel obstructionSmall bowel obstruction
Batteries
If in esophagus, treat with removalIf in esophagus, treat with removal Most recommend removal endoscopically if Most recommend removal endoscopically if
in stomachin stomach Difficulty arises if already in small bowelDifficulty arises if already in small bowel
would require laparotomy to removewould require laparotomy to remove reports of ulceration/perforation as well reports of ulceration/perforation as well
as successful passageas successful passage
Question 2?Why are Pediatric Surgeons so interested in flatus?
Contrary to popular belief, kids (and adults) with obstruction can still have bowel movements, but they won’t pass gas!
Summary
Bowel ObstructionBowel Obstruction AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception
NECNEC The Acute GroinThe Acute Groin Bleeding Meckel’sBleeding Meckel’s Foreign BodiesForeign Bodies