Surgical Problems in Children

1. Surgical Problems in Children BY Ragheb Assaf ,MD

3. Pyloric stenosis Hypertrophy of the gastric outlet 1:150 males, 1:750 females 2-12 weeks of age Repetitive vomiting Projectile Non-bilious Dehydration Hypochloremic alkalosis Exam Visible peristaltic wave Palpable “olive” to right of umbilicus

4. Pyloric stenosis: Diagnosis

5. Pyloric stenosis :treatment

6. Surgical treatment

7. Malrotation Failure of midgut to rotate into normal anatomic position during development Colon and cecum in left Duodenum on right side Bilious vomiting Peritoneal (Ladd) bands cause partial bowel obstruction High risk for...

8. Midgut volvulus Twisting of bowel around its mesentery and vascular supply Leads to ischemia, infarction, perforation, necrosis Presentation: lethargy, abdominal distention, bloody stools

9. MALROTATION Must consider in every infant with bilious emesis 30% present within first week of life 50% within first month Midgut volvulus with necrosis disastrous Can lead to SBS, death

10. CLINICAL PRESENTATION of MALROTATION Sudden onset of bilious emesis in 95% Abdominal distention common Blood stool + Bloody vomitus or diarrhea in 30%

11. RADIOLOGIC DX of MALROTATION KUB:Gasless abdomen, SBO, “double bubble” Contrast study: spiral or corkscrew appearance UTS: reversed position of SMA/SMV Study MUST be expeditious

12. PREOPERATIVE PREPARATION: MALROTATION WITH VOLVULUS Labs / unnecessary Mortality remains as high as 28% Preoperative preparation ?? NONE !! ...GO TO OR…. QUICKLY

13. OPERATIVE CORRECTION of MALROTATION Ladd procedure Position of corrected malrotation Small bowel descends on Right Large bowel on Left Appendix potentially in LUQ ? Removed Role of second look operation

14. Duodenal atresia Obliteration of lumen Failure to recanalize Neonatal bilious vomiting Associations Prematurity Congenital heart defects Trisomy 21

15. Meconium ileus CYSTIC FIBROSIS First manifestation in 15% of CF cases Thick meconium impacts in ileum Abdominal distention Bilious vomiting Risk for Volvulus Perforation

16. Intussusception Most common cause of intestinal obstruction between 3 mo - 6 yrs 2/3 cases occur <2 yrs Male/Female=4:1 75-95% Ileocolic >90% idiopathic; Meckel’s, Peyer’s patches, tumors, polyps

17. Intussusception Telescoping of one segment of bowel into another Ileocolonic most common 6 mos – 3 years old Progressive course Intermittent acute abd. pain Vomiting Bloody stools (currant jelly) Fever, lethargy Palpable sausage-shaped mass in upper abdomen

18. Intussusception: Presentation Abdominal pain, vomiting and rectal bleeding triad seen in < 1/3 of cases. 85% display only colicky abdominal pain often 1-5minutes of crying and pain separated by 3-30 minutes of nl behavior 75% have vomiting (develops after 6-12 hrs) 40% rectal bleeding Up to 10%: Lethargy only

19. Intussusception: Diagnosis Phys Exam: 25-89% may have variably tender sausage shaped mass; Dance’s sign: empty RLQ U/S: target, pseudokidney, radiologist dependent; if high suspicion, order the barium enema

20. Intussusception: Management Enema: diagnostic & therapeutic, “coiled spring” Surgery must be consulted prior to study. Barium vs. Air- 80% correction if within first 12-24 hrs. Air Enema- safer if perforation 5-10% recurrence rate in first 24-48h after barium enema reduction If free air on films or signs of peritonitis, do not administer barium, prepare child for surgery

21. Intussusception Management Ultrasound : Hydrostatic pressure reduces the intussusception Surgeon must be involved directly If enema reduction fails Small bowel intussusceptions require surgical reduction

22. Intussusception

23. Meckel’s diverticulum Remnant of omphalomesenteric duct Painless rectal bleeding Less commonly: intuss., volvulus, perforation Diagnosis CT scan Nuclear medicine scan Endoscopy Treatment Surgical resection

24. Appendicitis 80,000 cases in children/year /in USA Rare in children < 2years 20-40% misdiagnosed on initial exam 50-70% perforation rate in pre-school Mortality Rates of 5% in perforated vs 0.1% in non-perforated appendicitis

25. Appendicitis Pathophysiology: obstruction of appendix by fecalith or lymphoid tissue causes congestion, distention, ischemia, infection & perforation.

26. History Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific Anorexia is the most common of associated symptoms Vomiting is more variable, occuring in about ½ of patients

27. Physical Exam Findings depend on duration of illness prior to exam. Early on patients may not have localized tenderness With progression there is tenderness to deep palpation over McBurney’s point

28. Physical Exam McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS Rovsing’s: pain in RLQ with palpation to LLQ Rectal exam: pain can be most pronounced if the patient has pelvic appendix

29. Physical Exam Fever: another late finding. At the onset of pain fever is usually not found. Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture

30. Diagnosis CBC: the WBC is of limited value. Sensitivity of an elevated WBC is 70-90%, but specificity is very low. CRP and ESR have been studied with mixed results

31. Diagnosis Imaging studies: include X-rays, US, CT Xrays of abd are abnormal in 24-95% Abnormal findings include: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air Abdominal xrays have limited use b/c the findings are seen in multiple other processes

32. Diagnosis Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter

33. Diagnosis CT appears to change management decisions and decreases unnecessary appendectomies in girl, but it is not as useful for changing management in boy.

34. Treatment Appendectomy is the standard of care Patients should be NPO, given IVF, and preoperative antibiotics Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation

35. Hirschsprung’s disease Congenital absence of ganglion cells in distal rectum - and varying distance proximally Lack of peristalsis causes colonic obstruction Abdominal distention Failure to pass meconium Fever and diarrhea suggest “toxic megacolon”

36. Hirschsprung’s

37. Hirschsprung’s

38. Transanal pull-through

39. Inguinal hernia Most common surgical problem More common in male and premature infants Intestinal segment entering into scrotum through processus vaginalis Does not resolve spontaneously Painless scrotal bulge Increases in size with crying/straining Management Reducible: refer to surgery for repair Incarcerated: immediate surgical consult

40. Umbilical hernia Incomplete closure of umbilical ring fascia More common in premature and African-American infants Usually close by 2-4 yrs Refer to surgery if: Larger than 1.5 cm at 2 yrs Present after 4 yrs Supraumbilical hernia : Refer to surgery

41. Hypospadias Abnormal low position of urethral meatus Absence of ventral foreskin Associations Undescended testes Urinary tract anomalies Management Avoid circumcision Refer to surgeon

42. Phimosis vs. Paraphimosis

43. Scrotal swelling PAINLESS Hydrocele Varicocele Spermatocele Inguinal hernia PAINFUL Testicular torsion Epididymitis Orchitis Incarcerated hernia

44. Hydrocele

45. Cryptorchidism Undescended testicle(s) Spontaneous descent does not occur beyond age 1 yr Bilateral in 1/3 of cases Associations Inguinal hernia Hypospadias Higher incidence of Testicular torsion Infertility Cancer in cryptorchid testis

46. Cryptorchidism Endocrine eval. Refer early: 6-12 mos of age hCG stimulation test Can aid in descent Karyotype if hypospadias co-exists Surgery Orchidopexy Usually in1- 2nd yr of life

47. Testicular torsion Twisting of testis around spermatic cord Caused by abnormal fixation of testis to scrotum Vascular supply compromised Acute painful scrotal swelling Severe tenderness Redness or dusky color Testis elevated Cremasteric reflex absent

49. Neonatal torsion About 10% (prenatal 70% and postnatal 30%) It presents as a firm asymptomatic testicular mass with in a high or inguinal position and bruising of the scrotal skin. No viability at exploration in 80-100% of cases.

50. Torsion

51. management In the patient with acute surgical scrotal pain ,immediate surgical consultation is essential . Surgical exploration , detorsion and fixation.

52. Outcome Ischemic testicular damage related to the number of turns of the spermatic cord and the duration of torsion. All cases with a torsion > 360* and > 24h duration will have testicular loss or severe atrophy if the testis left in situ .

53. What to do? Always undress the child for exam Don’t forget Intussusception in lethargic children Utilize imaging liberally when child looks sick and know your radiologist’s expertise Any type of blood in stool may be due to Intussusception (not only currant jelly) Vomiting in infants should not be taken seriously Be conservative with children w/ unclear dx

54. What not to do Don’t tell a patient that they DO NOT have appendicitis Don’t let a normal X-ray or U/S fool you Don’t forget to ask parents/child with vomiting about abdominal pain

55. Questions or Comments