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I Need a Surgeon STAT!:When to Call Pediatric

General Surgery

Carrie M. Wilson, RN, CPNP-PC, CPNP-AC, WCC

Pediatric Nurse Practitioner

Pediatric General Surgery

Objectives

1) Identify signs and symptoms of emergent vs. non-emergent surgical conditions in pediatric patients.

2) Describe different evaluation methods (i.e. clinical assessment vs. imaging vs. laboratory data) in identifying and treating acute and non-acute pediatric surgical consults

Case Study #1

1 ½ year old female with a “pea-size lump” in left labia noted by PCP within the last week at 15 month WBE. No mention how long “lump” present before PCP visit. No nausea, vomiting. Pt eating, drinking well. No fevers. On exam, “lump” non-reducible.

Case Study #1

Differential Diagnosis? Lymph node

Mass

Hernia (direct or indirect)

Abscess

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Case Study #2

23 day old full-term female with uneventful first few weeks at home (uncomplicated delivery) who started with non-bilious emesis at 2 ½ weeks ago, progressively worsening. She vomits within 5 minutes of breastmilk feeds and “is hungry again.” No fevers. No URI. Stooling normally, passed meconium.

Case Study #2

Differntial Diagnoses: Malrotation with volvulus

Hirschsprung’s

Pyloric stenosis

Reflux

Case Study #3

10 week old male, ex-32 week gestation male infant with bilateral “inguinal bulges” seen by PCP at 2 month WBE referred for eval. Pt breastfeeding well. Mom remembers a “Doctor saying once” possible “hernia on the right side.” No emesis. Otherwise healthy.

Differential Diagnoses

Hydrocele

Retractile testis

Undescended testis

Varicocele

Testicular tumor

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Pediatric General Surgery Referrals

Total number of new evals in Pediatric General Surgery clinic in 2012=822

Top Outpatient Referrals: Other cellulitis and abscess-Buttock

Inguinal hernia, without mention of obstruction or gangrene, unilateral

Umbilical hernia

Other cellulitis and abscess-Leg, except foot (includes ankle,hip,knee,thigh)

Abdominal Surgical Consults

Urgent

Hypertropic Pyloric Stenosis

Incarcerated Hernias (Umbilical, Inguinal, Epigastric, Ventral, Incisional)

Intussusception

Abscesses

Lymphadenopathy

Appendicitis

Ovarian Torsion

Non-urgent

Hydroceles

Undescended Testes

Hernias not-incarcerated (Umbilical, Inguinal, Epigastric, Ventral, Incisional)

Neck masses

Abscesses

Lymphadenopathy

Hypertrophic Pyloric Stenosis

Acquired condition where the circumferential muscle of the pyloric muscle becomes thickened causing elongation of pyloric channel

Pedsurg.ucsf.edu

Hypertrophic Pyloric Stenosis

1-4/1000 live births

Caucasian (less in other races)

4:1 males (fullterm)

Familial (inherited more from mothers than fathers)

Symptoms: Progressie, projectile emesis, NBNB

Onset:3-6 weeks*

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Hypertropic Pyloric StenosisWorkup:

Labs: BMP-Metabolic alkalosis, hypocalcemia, hypochloremic, hypokalmeia hypoglycemia, elevated unconjugated bilirubin; CBC (r/o baseline anemia)

Clinical exam-palpable olive* (small oval mass in midepigastrum), acutely ill (dehydrated)

Pyloric Ultrasound-Dx: Diameter & channel length>17mm, wall thickness>4mm, NO ULTRASOUND if palpable olive w/hx

HPS“String sign”

HPS

Pylorus 2.2cm x 4mm

Case Study #2

Her labs were Cl=107, CO2=24. She had low uop. Fluid resuscitation. And she went to OR the next day for pyloromyotomy.

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Hernia

Hernia-protrusion of tissue through abnormal opening

Drugline.org

Inguinal Hernias

Indirect (congenital)-peritoneal contents (normally bowel) through processus vaginalis and down spermatic cord (males)/round ligament (females)

In females-Possible ovary or fallopian tube

10-20/1000 live births

More common in males (3:1) and premature infants (16-25%)

Inguinal Hernias

In children-most inguinal hernias indirect

1% of pediatric hernias-Direct hernias

Indirect-arise lateral to the inferior epigastric vessels

Direct-Medial to vessels and bulges through weakened posterior wall of inguinal canal

Inguinal Hernias

Browne, et al, 2013

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Inguinal Hernia Inguinal Hernia

Case Study #1

Inguinal hernia with incarcerated ovary Mass is ovary-non-reducible

Inguinal hernias (bowel)~1% in females-soft, reducible

Femoral hernia rare (1% of all hernias)

Timing of operative repair?

Would ultrasound be helpful in this case?

Possibility of testis instead of ovary. Genetics testing?

Case Study #3-Bilateral Inguinal Hernias (BIH)

Elective repair

Anesthesia risk

Post conceptual age

Timing of repair

Risk of strangulation/ischemic injury to gonad

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Emergent repair?Unable to reduce, risk of strangulation

Bowel contents stuck through ring

More common in first year of life

Exam: Firm, hard, tender mass

Erythema, blue mass

Fussy, inconsolable, vomiting, abdominal distension

If reduced, then operative repair in next 24-48 hours

Umbilical Hernia (UH)UH occur when the fascial ring, which

surrounds the umbilical cord and vessels, fails to close after birth

AA> Caucasians

Males=Females

Inc. incidence in Down syndrome (DS), hypothyroidism, & Beckwith-Weidemann syndrome

Umbilical Hernia

Elective repair if present >3-4 yrs of age

Repair prior to 3 yrs of age, inc. risk of recurrence

Repair UH < 3 yrs of age for large defects

Educate on UH & signs of incarceration

No labs/imaging, just clinical exam

Umbilical Hernia

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Diastasis Recti

Newborns. Standford.edu

HydroceleHydrocele – painless cyst formed by

tunica vaginalis that contains fluid

Occur when fluid in or above the scrotum through a patent processus vaginalis connected to peritoneal cavity

Males-1st few months of life

Resolve by 1 yr of age

Persistent hydrocele-communicating-Elective repair

No labs/imaging, just clinical exam

Hydrocele

Browne, et al, 2013

Undescended Testis Cryptorchidism-failure of the testis to

descend into the scrotum during gestation

More common in premature males (60-70%) with lower birth weight (<1500grams)

2-4% of males

~95% with associated hernia

Diagnosis: By clinical exam

No labs. Possible imaging-inguinal/scrotal ultrasound if non-palpable testis. Surgeon to examine prior to ordering imaging.

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Undescended Testis

Palpable

Retractile

Ectopic

True undescended testis

Nonpalpable

Intraabdominal

Absent

Undescended Testis

Elective repair if no testicular descent by 6 months of age

Testis needs cool environment of scrotum to produce male hormones & sperm

Inc. risk of infertility and cancer later in life if exposed to higher temps

Epigastric Hernia

Located in the upper, middle abdomen

May trap fat

Surgical repair (elective)

No labs/imaging

Neck Masses Neck masses

Cysts• Brachial Cleft Remnants

• Thyroglossal Duct Cyst

Lymphangiomas

Hemangiomas & Vascular Malformations

Lymphadenopathy

Lymphadenitis

Sebaceous Cysts• Dermoid

• Pilomatrixoma

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Brachial Cleft Remnant In fifth week of fetal development, major head and neck

structures are formed. The five pharyngeal arches (bands of tissue) are important structures that are formed. These arches contain primitive connective tissue that becomes cartilage, bone, muscle and blood vessels. Incomplete, failed, or persistent embryonic development of these arches results in several anomalies or defects in the neck.

Ultrasound may be useful to differentiate.www.childrenshospital.org

Thyroglossal Duct Cyst In development of thyroid gland, starts as a group of

cells that are located at the base of the tongue in the back of the mouth.

During embryological development, the thyroid cells move down a canal, called the thyroglossal duct, to the final location of the thyroid in the neck.

Once the thyroid reaches its final location, the duct involutes, or disappears.

If duct not disappear,

portions of the duct can create

pockets, called thyroglossal duct

Cysts. Fill withfluid or mucus.

Ultrasound may be useful.

Lymphangioma Benign

Lymphangiomas are malformations of the lymphatic system

Fluid unable to drain becomes a loculated mass

Congenital or acquired

Size, location, interference with vital structures (functional compromise), and type-determine surgical intervention

No labs/imaging

Hemangioma Benign

Self-involuting tumor

Increased abnormal and

normal vessels filled with blood

Rubbery, bright red http://www.m-cm.net

Appears in first few weeks of life, resolve by 10yrs of age

Treatment: rarely surgical, trial: pulsed laser, propranolol, derm referral, corticosteroids (injection), Vincristine, Interferon

No labs/imaging

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Lymphadenopathy Lymphadenopathy is the enlargement or

inflammation of a lymph node.

Abnormal in size, number, mobility.

Benign vs. malignant

History: duration, change in size, treatment?, age of pt, symptoms (fever, weight loss, night sweats, recent travel, sick exposure, immunizations UTD?, insect bites, bruising, petechiae)

Lympadenopathy Exam

Location

Consistency (hard, solid, soft)

Fluctuance

Texture (smooth/nodular)

Mobility (movable/fixed)

Tenderness

Erythema

Skin change

Other nodes (distribution, size)

Lymphadenopathy

Workup: Labs: CBC with diff, EBV titers, CMV, throat

culture (if symptomatic), mono spot

Imaging: Ultrasound (r/o abscess if fluctuance and/or erythema), CXR (r/o masses)

Possible biopsy (needle or excisional)

Other diffentials of lymphadenopathy: lymphadenitis, Mononucleosis, reactive lymph node (URI, OM, pharyngitis, skin lesion)

Sebaceous Cysts

Sebaceous cyst is a rounded edematous area formed by an abnormal sac of retained sebum from the sabeaceous follicles Types:

• Dermoids (ectodermal: sebaceous glands, hair follicles, connective tissue)

• Pilomatricoma (calcified epithelioma of Malherbe)

• Labs and imaging not usually done.

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Sebaceous Cysts

Pilomatrixoma Dermoid

Perridermatology.com

Other

Pilonidal sinus

Soft tissue Abscesses

Ganglion cysts

Pilonidal mass vs Pilonidal Pilonidal mass

Myxopapillary Ependymoma Rarely occurs in pelvic cavity

In pediatrics, usually presents intracranial

In adults, in spinal

Most anaplastic

Treatment: Full resection, clear margins

Case: 12 year old male with 1-2 week hx of mass

Imaging (CT chest, abd., pelvis, Bone scan, MRI brain, & then continued imaging q3months with hemoc with pelvic MRI)

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Pilonidal Abscess Perirectal Abscess/fistula

Abscesses

Drainage

Peri-rectals-if reoccur refer to Pediatric General Surgery for possible Exam under Anesthesia (EUA), fistulectomy

Clinical Manifestations of Abscess

Erythema

Swelling

Pain

Exudate

Warm to touch

Fluctuance

Fever

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Abscesses Abscess

Incision & Drainage

Clindamycin

Counter Incisions

Change to Vancomycin after adequate drainage procedure

Utility of ultrasound?

F/u cultures, resistant to clinda and/or bactrim?

Clinical Manifestations of Cellulitis

Erythema, Induration extending onto skin around abscess/boil

Over a joint

Impairs mobility/ROM

Fever

Cellulitis

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Antibiogram-EU Abscess Antibiogram

Ganglion Cysts

Benign cysts

Develop along tendons or joints of wrists or hands. Possibly of ankles and feet.

Typically round or oval and are filled with a jelly-like fluid.

www.assh.org

Granuloma annulareIntussusception

3 months-3 yrs, small intestine into cecum

Crampy, intermittent abd. Pain, currant jelly stools, lethargy, dehydration

Hypaque (air) vs. water soluble contrast vs. barium enemas-dx. & Tx

OR-possible bowel resection, possible ostomy

Lead points (lymph node, lymphoma, meckel’s)

Reoccurence-u/s

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Intussusception

Workup: Labs: BMP, CBC

Imaging: use of abdominal film, obstructive series, Ultrasound

Intussusception

Intussusception Appendicitis Sudden, onset abdominal pain localizing in

RLQ, pain on abdominal exam

+Psoas & obturator signs

Elevated WBC, with left shift

Fever, N/V

Labs: CBC with diff, BMP (if dehydrated)

Imaging: Ultrasound (if thin), CT scan of abdomen/pelvis with PO & IV contrast if equivacol exam, and unable to visualize appendix on u/s

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Ovarian Torsion

Rotation of the ovary, which occludes ovarian artery and/or vein

Sharp, abrupt onset of pain

N/V

On abdominal exam: no peritoneal signs

Labs: Hcg, CBC, UA

Imaging: Doppler pelvic ultrasound (need full bladder)

Ovarian Torsion Case Study 10 year old female with RLQ abdominal pain x 2

days with 6-7 emesis. Pain progressively worsened and worse with movement. OSH transfer. Constipation x 1 month with loose stools since pain. Febrile day of transfer. Currently on menses. OSH CT abd & pelvis found 7.6 x 6.2 x 6.1 cm solid/cystic mass in pelvic cul-de-sac. No change in urinary habits. Decreased PO intake. Sib with viral GE. OSH CBC with leukocystosis.

Ovarian Torsion Case Study

PMH: Acne, menses onset: 9yrs

Exam: soft, non-distended, tender to palpation and percussion, R>L lower abdomen

In OR-Dx laparoscopy, detorsion of Right ovary

Findings: cyst of left fallopian tube, enlarged right ovary with preop rupture, right ovary and fallopian tube torsed

Path no malignancy cytology, and acute inflammation, fibrin, & reactive mesothelial cells

Chest Wall DeformitiesPectus Carinatum

Pigeon chestPectus Excavatum

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Haller index CT of chest vs. MRI (Surgeon to order, lower

radiation CT of chest)

Measures deepest part of the pectus

Side to side inside the rib cage and dividing that measurement by the sternal-vertebral body distance (Swoveland, et al, 2001)

Nl chest <2.5

Severe pectus >3.25

Need this measurement for insurance coverage

Summary Clinical exam and assessment key to driving

the imaging study and further testing!

Call Pediatric General Surgery, 314-454-6022

Call Children’s Direct to talk to a Pediatric General Surgeon or Pediatric Surgical Nurse Practitioner, 314-747-7001

References Browne, N.T., et al, 3rd edition of Nursing care of the pediatric surgical patient, 2013. Burlington, MA: Jones &

Bartlett Learning, LLC.

Burns, CE, Brady, MA, Dunn, AM, Blosser, CG, & Starr, NB. Pediatric primary care: A handbook for nurse practitioners. 5nd edition, Philadephia, 2013, Saunders/Elsevier..

Fritz, SA, Long, M, Gaebelein, CJ, Martin, M, Hogan, PG, & Yetter, J. Practices and procedures to prevent the transmission of skin and soft tissue infections in high school athletes. The Journal of School Nursing, 28(5): 389-396, 2012.

Hockenberry MJ, Wilson D. Wong's nursing care of infants and children, ed 9, St. Louis, 2011, Mosby/Elsevier.

Holcomb, GW, & Murphy, JP. Ashcraft's pediatric surgery, ed 5, Philadephia, 2010, Saunders/Elsevier.

Kelly, MN, Tuli, SS, Usher, S, Tuli, SY. A 6-year old with acute-onset generalized lympadenopathy. Journal of Pediatric Health Care, 26(6), 465-470, 2012.

Moss, RL, Skarsgard, ED, Kosloske, AM, Smith, BM. Case studies in pediatric surgery, St. Louis, 2000, McGraw-Hill.

Pasaron, R.Clinical Problem-Solving: Three rare conditions-one pediatric surgical patient. Journal of Pediatric Nursing, 27, 295-298, 2012.

Raffensperger, JG. Swenson’s pediatric surgery, 5th edition, Norwalk, 1990, Appleton & Lange.

Saito, J. Beyond appendicitis: evaluation and surgical treatment of pediatric acute abdominal pain. Current Opinion Pediatrics, 24. 357-364. 2012.

Urden, LD, Stacy, KM, Lough, ME. Critical care nursing, 6th edition, St. Louis, 2010, Mosby/Elsevier.

Questions?

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Don’t Be a Superhero, Call a Surgeon!