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My Tummy Hurts

My Tummy Hurts. Joshua B Glenn, MD Assistant Professor of Surgery Director Pediatric Surgery Mercer University School of Medicine Navicent Health Children’s Hospital. Disclosures. Financial disclosure None Unapproved/Unlabeled Use None. Objectives.

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My Tummy Hurts

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  1. My Tummy Hurts Joshua B Glenn, MD Assistant Professor of Surgery Director Pediatric Surgery Mercer University School of Medicine Navicent Health Children’s Hospital

  2. Disclosures • Financial disclosure • None • Unapproved/Unlabeled Use • None

  3. Objectives • Discuss common surgical conditions in infants and children • Recognize surgical emergencies

  4. Emesis • Bilious – Surgical Emergency • Malrotation with volvulus • Obstruction • Intussusception • Adhesive obstruction • Nonbilious • Hypertophic Pyloric Stenosis • GERD • Ileus

  5. Emesis • 4 week old infant with nonbilious emesis for 1 week • Progressively worsening • Happens 10 mins after feeds • “spews across the room” • Often many formula changes attempted • Lethargic, sunken fontanelle, poor skin turgor • Olive palpated on exam • Tests?

  6. Pyloric Stenosis • Diagnosis • US • UGI • Labs • BMP • No CBC required

  7. Pyloric Stenosis • 1:150 live births • Rare in African Americans and Asians • Males 4x more common than females • Hereditary predisposition • Hypertrophied pyloric muscle • Unknown etiology • Hypochloremic, hypokalemic metabolic alkalosis

  8. Pyloric Stenosis • Volume loss causes aldosterone secretion • Na+ conserved in exchange for H+ in proximal tubule (kidney protects volume over pH); H+ in urine aciduria, worsening metabolic alkalosis • Na+ resorption/K+ loss (exchange) in late distal tubule; K+ loss exacerbated by K+/H+ exchange in distal tubule in an effort to correct pH

  9. Pyloric Stenosis • Medical Emergency – Not a surgical Emergency • Effective preoperative rehydration is imperative • Reestablish ECFV • Replace Na+ and Cl- to enable kidney to excrete HCO3-, correcting alkalosis (Cl-/HCO3- exchanger) • Replace K+ - Do not believe the hyperkalemia on the Heel stick • Replace with D5 ½ NS with 20+ meq KCl at 150 ml/kg/day (maintenance and ½); Severe Dehydration bolus with 20 ml/kg NS

  10. Pyloric Stenosis

  11. Emesis #2 • 2 month old infant, former 35 week preemie • Poor weight gain/failure to thrive • Nonbilious emesis after feeds • ? Acute Life-Threatening Events (ALTE) – “turned blue, stopped breathing for a second” • Questions and workup?

  12. Reflux Disease – Diagnostic Tests • Good clinical history – nothing else needed • UGI – 50-60% sensitivity • Primary use is confirming normal anatomy • Milk Scan – 70-80% sensitivity • pH probe – gold standard • 90% sensitivity • Hard to get • Have to be off meds

  13. Reflux Disease • Babies throw up a lot • Reflux is usually self limiting and/or responds to medical therapy • When to think of surgery • Younger infants • Failure to thrive • ALTE/Respiratory Symptoms • Neurologic impairment • Older infants • Failure medical management • Esophagitis • recurrent/refractory respiratory symptoms (aspiration pneumonia, RAD)

  14. Emesis #3 • 2 yr old with low grade fever, cough and runny nose x 3 days • Intense, crampy pain – “balls legs up and screams” • Green tinged emesis • Bloody stool

  15. Intussusception • Viral Symptoms • Paroxysmal, Crampy Abdominal pain • Currant-Jelly Stools • Emesis (may be bilious) • Often can feel mass RLQ • Contrast enema if no peritoneal signs • Surgical Reduction • Laparoscopic or open

  16. Emesis #4 • Newborn male 2 day old has fed well now with “green spits” • Slightly distended • Uncomfortable, lethargic

  17. Bilious Emesis

  18. Malrotation

  19. Malrotation

  20. Malrotation

  21. Malrotation

  22. Malrotation with volvulus • Must consider in every child with bilious emesis • Many variations of malrotation/nonfixation • 30% present within 1st week of life • 50% within first month • KUB – gasless, can be normal if early(does not rule out) • Contrast study – UGI best test • US – reversal of position of SMA/SMV • Whatever you do, do it fast

  23. Malrotation with volvulus • No labs - need to go to OR ASAP • IVF if can be done expeditiously • Mortality remains high – 28% • SBS, intestinal transplant • Operation • Ladd procedure • Detorsion of bowel • Divide abnormal bands • Small bowel right, colon left • Remove Appendix

  24. Emesis #5 • 6 yr old with low grade temp and abdominal pain since this AM • Started at umbilicus • Pain started first now has had nonbilious emesis • Pain now at RLQ • Doesn’t want to walk

  25. Appendicitis • Low grade fever • Anorexia • Luekocytosis • RLQ pain • Diagnosis • Physical Exam • US (operator dependent) • CT (IV contrast only is adequate) • High incidence of perforation children <5

  26. Emesis #6 • 3 day old infant with abdominal distention and bilious emesis • Physical exam normal except distended firm abdomen • OGT with bilious material • Anus patent and in normal position • No hernias • Questions/Workup?

  27. Low intestinal obstruction • Ileal/Colonic Atresia • Meconium Ileus • Hirschsprung’s Disease • Meconium Plug • Micro-colon • Anorectal malformation • Medical causes • Sepsis, ileus, electrolyte imbalance, thyroid disease • How to Diagnose? Tests?

  28. Hirschsprung’s Disease • Lack of progression of propulsive waves and relaxation of internal and anal sphincter due to anganglionosis • Etiology unknown • Genetic factors • RET-tyrosine receptor kinase • Presentation • Neonate – failure to pass meconium, distention • Later – failure to thrive, constipation, episodes of distention and watery diarrhea with “explosive stools”

  29. Hirschsprung’s Disease • Management • Decompression – NGT, rectal irrigations • Antibiotics • IVF • Diagnosis • BE • Rectal biopsy • Surgery • Colostomy • Definitive procedure • Swenson, Duhamel, Soave

  30. Hirschsprung’s Disease • Complications • Constipation • Fecal soiling • Enterocolitis

  31. Enterocolitis • Commonly misdiagnosed as gastroeneteritis • Can occur after surgical correction of HD • Distended, tender abdomen • Explosive gas and stool on DRE • Prompt recognition essential • Aggressive IV fluid resuscitation • Broad Spectrum Antibiotics • Rectal washouts with warm saline every 6 hrs Can be life threatening

  32. Put duodenal atresia xray here

  33. Duodenal Atresia • Failure of recannalization of duodenum • 3rd week embryonic development 2nd portion duodenum gives off pancreatic and biliary buds • Duodenum goes through “solid” phase then recannalizes by coalescence of vacuoles • Stenosis, windsock deformity, atresia • 50% associated anomalies • Cardiac, GU, anorectal • 40% with trisomy 21

  34. Duodenal Atresia • Polyhydramnios secondary to intestinal obstruction • Emesis after birth – clear or bilious, aspiration >20ml via OG tube • Distention often not present • Decompress, IVF, look for associated anomalies • ECHO, renal US

  35. Put tef xray here

  36. Esophageal Atresia Tracheoesophageal Fistula • VACTERL – vertebral, anorectal, TEF, renal, limb abnormalities • Inability to pass NG • Initial management • Elevate HOB, 10 french sump catheter in upper pouch

  37. Esophageal Atresia Tracheoesophageal Fistula

  38. Insert CDH here

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