Surgical Emergencies in Children

1. Surgical Emergencies in Children Dr. WasmiAlfadhli,MD,FRCSC Pediatric Surgery Department IbnSina Hospital 9/4/2012

2. They aren’t just small adults • Size does matter! (so does age) • Vital signs • Fluid requirements • Etc…

3. How can we know or suspect abdominal pain in infants? • PERSISTANT CRYING • REFUSAL OF FEEDING • IRRITABILITY • FLEXION OF THIGHS ON THE ABDOMEN

4. History • Personal data: • Chief complaint: • History of presenting illness: • pain? • Associated symptoms? • Previous episodes? • Past diagnosis & treatment? • Relation to food?

5. Past medical history? • Prenatal? • Nutritional? • Immunization? • Developmental? • Allergies?

6. History of trauma? • Drug history? • Family history? • Recent travel? • Social history?

7. Physical Examination • GENERAL INSPECTION • ABDOMINAL EXAMINATION • FULL EXAMINATION FOR EXTRA ABDOMINAL CAUSES

8. 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

9. Vital signs: • Pulse • Blood pressure • Temperature • Respiratory rate

10. 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

11. 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

12. Rectal Examination: • Indication: • 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

13. A CHILD WITH ACUTE ABDOMINAL PAIN

14. Case 1 • 1 year Male • Blood in stool • What's next? • Complete History and Physical Examination • ABC • DDx?

16. Meckel’sDiverticulum

17. During the third week of fetal development, the midgut opens into the yolk sac,remainingtemporarily connected by the vitellineduct • As intestinal maturation proceeds,thevitelline duct narrows. By the third month of embryogenesis, the duct disappears

18. 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

19. Clinical Presentation • Symptoms are usually absent unless complications occur • Bleeding • Obstruction • inflammation (with or without perforation)

21. Diagnosis • Meckel scan

22. Treatment

23. Intussusception

24. 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

25. 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

27. 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)

28. Clinical manifestation • Crampyabdo 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 jellystools are passed

29. 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

31. U/S

32. Treatment • Hydrostatic barium enema or pneumatic enema

33. If failed or contraindicated hydrostatic barium enema or pneumatic enema

35. Case 2 • 2 days old male • Term • BW 2.6 kg

36. DDx • Malrotation • Atresia (duodenal,jujenal,ilial and colonic) • Hirschsprung disease • Meconuim ilius • Meconuim plug

37. Malrotation

38. 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)

40. Clinical features • 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, Meckelsdiverticulum, intussusception.. • Onset is acute, vomiting is chief symptom (bile vomitus) • Be aware of a child vomiting green

41. 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

42. Imaging: • Paucity of gas in SB • Coiled duodenum on UGI series • Cecal malposition on contrast enema

43. Management • Management is Operative! • Urgent laparotomy essential to prevent gut infarction

47. Atresias

48. Atresias

49. TEF