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